Donna Zulman, MD, MS, is an Associate Professor in the Division of Primary Care and Population Health at Stanford University and Associate Director at VA Palo Alto’s Center for Innovation to Implementation (Ci2i). Dr. Zulman received her MD from the University of California, Los Angeles. After completing her residency in Internal Medicine at the University of Michigan, she received a Masters in Health and Health Care Research through the Robert Wood Johnson Clinical Scholars Program at the University of Michigan and the Ann Arbor VA.

Dr. Zulman received a VA Health Services Research & Development Career Development Award (2013-2018). Currently, her research focuses on improving health care delivery and patient-facing technology for individuals with complex medical and social needs. She is one of the PIs of the national VA Virtual Care Consortium of Research, and directs the VA Quality Enhancement Research Initiative focused on implementing and evaluating virtual care for Veterans with access barriers. Dr. Zulman also leads the Stanford Presence 5 research program, which focuses on interventions to foster physician humanism and connection with patients, and an associated initiative, Presence 5 for Racial Justice, that promotes antiracism communication strategies and interventions to advance health equity.

Dr. Zulman serves as an Associate Editor for the Journal of General Internal Medicine and Health Services Research, and directs an evaluation center for Stanford's Racial Equity to Advance a Community of Health program. She is actively involved in teaching and mentoring students, residents, and fellows at the VA, and at Stanford, where she directs a course entitled, Methods for Health Care Delivery Innovation, Implementation, and Evaluation. Dr. Zulman was the recipient of the Stanford McCormick Award for the Advancement of Women in Academic Medicine in 2016 and an Exceptional Mentor Award from the American Medical Women’s Association in 2020.

Administrative Appointments

  • Associate Professor, Division of Primary Care and Population Health, Department of Medicine, Stanford University (2021 - Present)
  • Associate Director, Center for Innovation to Implementation, VA Palo Alto Health Care System (2020 - Present)
  • Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System (2011 - Present)
  • Assistant Professor, Division of Primary Care and Population Health, Department of Medicine, Stanford University (2015 - 2021)
  • Instructor, Division of General Medical Disciplines, Department of Medicine, Stanford University (2011 - 2015)

Honors & Awards

  • James V. Burgess Methods Article-of-the-Year, Health Services Research (2021)
  • John A. Benson, Jr., MD Professionalism Article Prize, American Board of Internal Medicine Foundation (2021)
  • Exceptional Mentor Award, American Medical Women's Association (2020)
  • Award for Excellence in Clinical Investigation, Society for General Internal Medicine California-Hawaii Region (2016)
  • McCormick Award for the Advancement of Women in Academic Medicine, Stanford University School of Medicine (2016)
  • Career Development Award, VA Health Services Research & Development (2013-2018)
  • Milton W. Hamolsky Junior Faculty Scientific Presentation Award, Society for General Internal Medicine (2013)
  • Teaching Award for Division of General Medical Disciplines, Stanford University (2012)
  • Clinical Scholar, Robert Wood Johnson Foundation Clinical Scholars Program (2008-2011)
  • Member, Alpha Omega Alpha Honor Medical Society (2004)

Professional Education

  • BA, Human Biology, Stanford University (2000)
  • MD, University of California, Los Angeles (2005)
  • MS, Health and Health Care Research; Robert Wood Johnson Clinical Scholars Program, University of Michigan (2010)

Current Research and Scholarly Interests

- Design, implementation, and evaluation of health care delivery models for patients with complex medical, social and behavioral needs.
- Care transformation for patients with multiple chronic conditions through enhanced clinical decision support, patient-provider communication interventions, and patient self-management strategies.
- Effective communication and relationship-building in the clinical context
- Patient-facing technology (e.g., video-based care, eHealth technology) for individuals with access barriers and populations that require complex medical and social services.

Clinical Trials

  • Evaluation of Intensive Management Patient Aligned Care Team Not Recruiting

    This evaluation will examine the feasibility, implementation, and effectiveness of a quality improvement intervention-Intensive Management Patient Aligned Care Team (ImPACT)-for high-risk patients.

    Stanford is currently not accepting patients for this trial. For more information, please contact Donna Zulman, 650-725-7747.

    View full details

  • Shared Health Appointments and Reciprocal Enhanced Support Not Recruiting

    The purpose of this study is to evaluate the effectiveness of a peer-to-peer program (P2P) in addition to Shared Medical Appointments (SMAs) compared to SMAs alone for the treatment of diabetes in five VA health systems, and to study the implementation process in order to gather information required to disseminate the program more broadly in the VHA system.

    Stanford is currently not accepting patients for this trial.

    View full details


  • Social and Behavioral Determinants of Health in High-Risk Veterans, Veterans Affairs

    This study aims to identify social determinants of health (SDH) that are predictive of clinical, economic, and patient experience outcomes in Veterans, with the goal of informing VA selection of SDH measures for electronic health record integration.


    VA Palo Alto

  • VA Virtual Care Consortium of Research (VA Virtual Care CORE), VA HSR&D

    This award is supporting the development of a network of VA investigators and Operational partners to facilitate research that evaluates and improves the use of virtual care to enhance accessibility, capacity, and quality of VA health care and Veteran experience.


    795 Willow Road, Menlo Park, CA 94025

  • Stanford Presence 5: Enhancing Clinical Care Through Presence, Stanford University

    Gordon & Betty Moore Foundation 6382


    Division of Primary Care & Population Health

  • Enhancing Veterans' Access to Care through Video Telehealth Tablets, Center for Innovation to Implementation (Ci2i), VA Palo Alto

    VA QUERI PEI 18-205


    795 Willow Rd, Menlo Park

  • Evaluating Innovative Care Models for High-Utilizing Patients, VA HSR&D

    VA HSR&D PPO 13-117


    795 Willow Road, Menlo Park

  • Optimizing eHealth Applications for Multimorbid Patients, VA HSR&D

    VA HSR&D CDA 12-173


    795 Willow Road, Menlo Park

  • Care Coordination for High-Risk Veterans with Multiple Chronic Conditions, VA HSR&D (1/1/2018 - 12/31/2020)


    795 Willow Road, Menlo Park, CA 94025

Stanford Advisees

All Publications

  • Virtual Care, Telemedicine Visits, and Real Connection in the Era of COVID-19: Unforeseen Opportunity in the Face of Adversity. JAMA Zulman, D. M., Verghese, A. 2021; 325 (5): 437–38

    View details for DOI 10.1001/jama.2020.27304

    View details for PubMedID 33528520

  • Patient-Reported Social and Behavioral Determinants of Health and Estimated Risk of Hospitalization in High-Risk Veterans Affairs Patients. JAMA network open Zulman, D. M., Maciejewski, M. L., Grubber, J. M., Weidenbacher, H. J., Blalock, D. V., Zullig, L. L., Greene, L., Whitson, H. E., Hastings, S. N., Smith, V. A. 2020; 3 (10): e2021457


    Importance: Despite recognition of the association between individual social and behavioral determinants of health (SDH) and patient outcomes, little is known regarding the value of SDH in explaining variation in outcomes for high-risk patients.Objective: To describe SDH factors among veterans who are at high risk for hospitalization, and to determine whether adding patient-reported SDH measures to electronic health record (EHR) measures improves estimation of 90-day and 180-day all-cause hospital admission.Design, Setting, and Participants: A survey was mailed between April 16 and June 29, 2018, to a nationally representative sample of 10 000 Veterans Affairs (VA) patients whose 1-year risk of hospitalization or death was in the 75th percentile or higher based on a VA EHR-derived risk score. The survey included multiple SDH measures, such as resilience, social support, health literacy, smoking status, transportation barriers, and recent life stressors.Main Outcomes and Measures: The EHR-based characteristics of survey respondents and nonrespondents were compared using standardized differences. Estimation of 90-day and 180-day hospital admission risk was assessed for 3 logistic regression models: (1) a base model of all prespecified EHR-based covariates, (2) a restricted model of EHR-based covariates chosen via forward selection based on minimizing Akaike information criterion (AIC), and (3) a model of EHR- and survey-based covariates chosen via forward selection based on AIC minimization.Results: In total, 4685 individuals (response rate 46.9%) responded to the survey. Respondents were comparable to nonrespondents in most characteristics, but survey respondents were older (eg, >80 years old, 881 [18.8%] vs 800 [15.1%]), comprised a higher percentage of men (4391 [93.7%] vs 4794 [90.2%]), and were composed of more White non-Hispanic individuals (3366 [71.8%] vs 3259 [61.3%]). Based on AIC, the regression model with survey-based covariates and EHR-based covariates better estimated hospital admission at 90 days (AIC, 1947.7) and 180 days (AIC, 2951.9) than restricted models with only EHR-based covariates (AIC, 1980.2 at 90 days; AIC, 2981.9 at 180 days). This result was due to inclusion of self-reported measures such as marital or partner status, health-related locus of control, resilience, smoking status, health literacy, and medication insecurity.Conclusions and Relevance: Augmenting EHR data with patient-reported social information improved estimation of 90-day and 180-day hospitalization risk, highlighting specific SDH factors that might identify individuals who are at high risk for hospitalization.

    View details for DOI 10.1001/jamanetworkopen.2020.21457

    View details for PubMedID 33079198

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


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

    View details for DOI 10.1111/1475-6773.13263

    View details for PubMedID 31970757

  • 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. n., Tierney, A. A., Zionts, D. L., Safaeinili, N. n., Fischer, M. n., Thadaney Israni, S. n., Asch, S. M., Verghese, A. n. 2020; 323 (1): 70–81


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

    View details for DOI 10.1001/jama.2019.19003

    View details for PubMedID 31910284

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


    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 Identifier: NCT02932228.

    View details for DOI 10.1001/jamainternmed.2016.8021

    View details for PubMedID 28027338

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

    View details for DOI 10.1001/jama.2016.9538

    View details for PubMedID 27532804

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


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

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

    View details for Web of Science ID 000358359400012

    View details for PubMedCentralID PMC4510242

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

    View details for DOI 10.1136/bmjopen-2015-007771

    View details for PubMedID 25882486

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


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

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

    View details for PubMedID 24081443

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


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

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

    View details for Web of Science ID 000298280500014

    View details for PubMedID 22184687

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


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

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

    View details for Web of Science ID 000291701200020

    View details for PubMedID 21286840

  • Regional variation in financial hardship among US veterans during the COVID-19 pandemic. Health affairs scholar Hauschildt, K. E., Bui, D. P., Govier, D. J., Eaton, T. L., Viglianti, E. M., Ettman, C. K., McCready, H., Smith, V. A., O'Hare, A. M., Osborne, T. F., Boyko, E. J., Ioannou, G. N., Maciejewski, M. L., Bohnert, A. S., Hynes, D. M., Iwashyna, T. J., VA COVID-19 Observational Research Collaboratory (CORC), Chai, W., Bowling, B., Maciejewski, M., Womer, J., Iwashyna, T., Anderson, S., Bernstein, T., Cabrales, A., Hauschildt, K., Admon, A., Byrd, K., Cano, J., Curtis, J., DelMonico, E., Horowitz, D., Kamphius, L., Korpela, P., Kumbier, K., Langa, K., Prescott, H., Rouse, M., Saini, S., Seelye, S., Sussman, J., Wawrin, N., Monahan, M., Bohnert, A., Viglianti, E., Akgun, K., Aslan, M., Cheung, K., Li, Y., Mutalik, P., Rajeevan, N., Yan, L., Anderson, L., Berkowitz, T., Bogdan, J., Bosworth, H., Boucher, N., Cummin, G., Dennis, P., Floyd, B., Hastings, S. N., Kaufman, B., Meyer, C., Miles, A., Naylor, J., Shepherd-Banigan, M., Smith, V., Smith, B., Woods, C., Dobalian, A., Goetz, M., Ikuta, K., Ong, M., Shaukat, A., Backus, L., Ferguson, J., Osborne, T., Shahoumian, T., Veigulis, Z., Zulman, D., Bajema, K., Bui, D., Chen, J., Govier, D., Helfand, M., Hickok, A., Hough, C., McCready, H., Moss, A., Newell, S., Niederhausen, M., Nugent, S., Saha, S., Slatore, C., Takata, Y., Teo, A., Tuepker, A., Vranas, K., Winchell, K., Hynes, D., Boyko, E., Au, D., Baraff, A., Berry Wyatt, K., Borgerding, J., Burwick, N., Crothers, K., Davis, M., Doll, J., Dominitz, J., Eastment, M., Fan, V., Fox, A., Hawkins, E., Hebert, P., Hu, E., Korpak, A., Morelli, D., Peterson, A., Reddy, A., Shah, J., Showalter, W., Smith, N., Suri, P., Thomas, E., Turner, A., Vig, E., Wicks, K., Wong, E., Wysham, K., Ioannou, G., O'Hare, A., Jones, B., Jones, M., Knight, S. 2024; 2 (6): qxae075


    Geographic variation in hardship, especially health-related hardship, was identified prior to and during the pandemic, but we do not know whether this variation is consistent among Veterans Health Administration (VHA)-enrolled veterans, who reported markedly high rates of financial hardship during the pandemic, despite general and veteran-specific federal policy efforts aimed at reducing hardship. In a nationwide, regionally stratified sample of VHA-enrolled veterans, we examined whether the prevalence of financial hardship during the pandemic varied by US Census region. We found veterans in the South, compared with those in other census regions, reported higher rates of severe-to-extreme financial strain, using up all or most of their savings, being unable to pay for necessities, being contacted by collections, and changing their employment due to the kind of work they could perform. Regional variation in veteran financial hardship demonstrates a need for further research about the role and interaction of federal and state financial-assistance policies in shaping risks for financial hardship as well as potential opportunities to mitigate risks among veterans and reduce variation across regions.

    View details for DOI 10.1093/haschl/qxae075

    View details for PubMedID 38938272

  • Promoting Diversity, Equity, Inclusion, and Justice in Grantmaking for Health Care Research: A Pragmatic Review and Framework HEALTH EQUITY King, Z., Brown-Johnson, C., Forneret, A., Yang, D., Malcolm, E., Ginete, D. R., Mercado-Lara, E., Zulman, D. M. 2024; 8 (1): 391-405
  • Gender Differences in Adoption and Frequency of Virtual Primary Care Among Men and Women Veterans. Journal of women's health (2002) Ferguson, J. M., Goldstein, K. M., Zullig, L. L., Zulman, D. M. 2024


    Background: Women Veterans have unique health care utilization patterns; however, video-based primary care utilization among and between women and men has not been well examined. Methods: In a retrospective cohort study, we calculated gender-stratified video visit adoption (i.e., likelihood) and frequency (i.e., rate of use among users) between April 1, 2020, and March 31, 2022, by demographic and clinical characteristics known to impact health care utilization. Results: Among 5,389,139 Veterans (9.2% women), 32% of women and 18.6% of men had a video-based primary care visit over the 2-year study period. Gender interacted with Veteran characteristics and the likelihood of any video care. Men often had associations stronger in magnitude (both positive and negative) than women, including by age, rurality, history of housing instability, mental health conditions, and marital status. The direction of effect never diverged by gender. A positive association among women always coincided with a positive association among men, and vice versa, across all characteristics assessed. Only the risk ratio for video care use comparing Veterans of Black race with White race was stronger among women. In contrast to the video care adoption differences by gender, we found few differences in the frequency of video-based care by gender. Conclusions: The findings suggest there are fewer disparities by demographic and clinical characteristics in any video care use among women compared with men and little to no disparities in the frequency of video care use by gender. Understanding the variation in video care utilization by gender could help improve acceptance, appropriate utilization, and uptake of video-based visits for all.

    View details for DOI 10.1089/jwh.2023.0781

    View details for PubMedID 38629443

  • Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective. Clinical psychology review Fischer, R., Bailey, Y., Shankar, M., Safaeinili, N., Karl, J. A., Daly, A., Johnson, F. N., Winter, T., Arahanga-Doyle, H., Fox, R., Abubakar, A., Zulman, D. M. 2024; 110: 102425


    We introduce the bias and equivalence framework to highlight how concepts, methods, and tools from cultural psychology can contribute to successful cultural adaptation and implementation of behavioral interventions. To situate our contribution, we provide a review of recent cultural adaptation research and existing frameworks. We identified 68 different frameworks that have been cited when reporting cultural adaptations and highlight three major adaptation dimensions that can be used to differentiate adaptations. Regarding effectiveness, we found an average effect size of zr=0.24 (95%CI 0.20, 0.29) in 24 meta-analyses published since 2014, but also substantive differences across domains and unclear effects of the extent of cultural adaptations. To advance cultural adaptation efforts, we outline a framework that integrates key steps from previous cultural adaptation frameworks and highlight how cultural bias and equivalence considerations in conjunction with community engagement help a) in the diagnosis of behavioral or psychological problems, b) identification of possible interventions, c) the selection of specific mechanisms of behavior change, d) the specification and documentation of dose effects and thresholds for diagnosis, e) entry and exit points within intervention programs, and f) cost-benefit-sustainability discussions. We provide guiding questions that may help researchers when adapting interventions to novel cultural contexts.

    View details for DOI 10.1016/j.cpr.2024.102425

    View details for PubMedID 38614022

  • Development and Validation of a Measure to Assess Patient Experiences With Video Care Encounters. JAMA network open Slightam, C., SooHoo, S., Greene, L., Zulman, D. M., Kimerling, R. 2024; 7 (4): e245277


    As video-based care expands in many clinical settings, assessing patient experiences with this care modality will help optimize health care quality, safety, and communication.To develop and assess the psychometric properties of the video visit user experience (VVUE) measure, a patient-reported measure of experiences with video-based technology.In this survey study, veterans completed a web-based, mail, or telephone survey about their use of Veterans Healthcare Administration (VHA) virtual care between September 2021 and January 2022. The survey was completed by patients who reported having a VHA video visit on their own device or a VHA-issued device and linked to VHA utilization data for the 6 months following the survey. Data analysis was performed from March 2022 to February 2023.The survey included 19 items about experiences with video visits that were rated using a 4-point Likert-type scale (strongly disagree to strongly agree). First, an exploratory factor analysis was conducted to determine the factor structure and parsimonious set of items, using the McDonald Omega test to assess internal consistency reliability. Then, a confirmatory factor analysis was conducted to test structural validity, and bivariate correlations between VVUE and VHA health care engagement were calculated to test concurrent validity. Finally, predictive validity was assessed using logistic regression to determine whether VVUE was associated with future VHA video visit use.Among 1887 respondents included in the analyses, 83.2% (95% CI, 81.5%-84.8%) were male, 41.0% (95% CI, 38.8%-43.1%) were aged 65 years or older, and the majority had multiple chronic medical and mental health conditions. The exploratory factor analysis identified a 10-item single-factor VVUE measure (including questions about satisfaction, user-centeredness, technical quality, usefulness, and appropriateness), explaining 96% of the total variance, with acceptable internal consistency reliability (ω = 0.95). The confirmatory factor analysis results confirmed a single-factor solution (standardized root mean squared residual = 0.04). VVUE was positively associated with VHA health care engagement (ρ = 0.47; P < .001). Predictive validity models demonstrated that higher VVUE measure scores were associated with future use of video visits, where each 1-point increase on VVUE was associated with greater likelihood of having a video visit in subsequent 6 months (adjusted odds ratio, 1.04; 95% CI, 1.02-1.06).The findings of this study of veterans using video visits suggest that a brief measure is valid to capture veterans' experiences receiving VHA virtual care.

    View details for DOI 10.1001/jamanetworkopen.2024.5277

    View details for PubMedID 38578639

  • Realizing Virtual Care in VA: Supporting the Healthcare System's Journey Towards Enhanced Access, Engagement, and Outcomes. Journal of general internal medicine Hogan, T. P., Sherman, S. E., Dardashti, N., McMahon, N., Slightam, C., Zulman, D. M. 2024

    View details for DOI 10.1007/s11606-024-08618-9

    View details for PubMedID 38393612

  • Adoption and Sustained Use of Primary Care Video Visits Among Veterans with VA Video-Enabled Tablets. Journal of medical systems Dhanani, Z., Ferguson, J. M., Van Campen, J., Slightam, C., Heyworth, L., Zulman, D. M. 2024; 48 (1): 16


    In 2020, the U.S. Department of Veterans Affairs (VA) expanded an initiative to distribute video-enabled tablets to Veterans with limited virtual care access. We examined patient characteristics associated with adoption and sustained use of video-based primary care among Veterans. We conducted a retrospective cohort study of Veterans who received VA-issued tablets between 3/11/2020-9/10/2020. We used generalized linear models to evaluate the sociodemographic and clinical factors associated with video-based primary care adoption (i.e., likelihood of having a primary care video visit) and sustained use (i.e., rate of video care) in the six months after a Veteran received a VA-issued tablet. Of the 36,077 Veterans who received a tablet, 69% had at least one video-based visit within six months, and 24% had a video-based visit in primary care. Veterans with a history of housing instability or a mental health condition, and those meeting VA enrollment criteria for low-income were significantly less likely to adopt video-based primary care. However, among Veterans who had a video visit in primary care (e.g., those with at least one video visit), older Veterans, and Veterans with a mental health condition had more sustained use (higher rate) than younger Veterans or those without a mental health condition. We found no differences in adoption of video-based primary care by rurality, age, race, ethnicity, or low/moderate disability and high disability priority groups compared to Veterans with no special enrollment category. VA's tablet initiative has supported many Veterans with complex needs in accessing primary care by video. While Veterans with certain social and clinical challenges were less likely to have a video visit, those who adopted video telehealth generally had similar or higher rates of sustained use. These patterns suggest opportunities for tailored interventions that focus on needs specific to initial uptake vs. sustained use of video care.

    View details for DOI 10.1007/s10916-024-02035-5

    View details for PubMedID 38289373

    View details for PubMedCentralID 7816740

  • Building Authentic Connection in the Patient-Physician Relationship. Journal of primary care & community health Fuehrer, S., Weil, A., Osterberg, L. G., Zulman, D. M., Meunier, M. R., Schwartz, R. 2024; 15: 21501319231225996


    Delivering optimal patient care is impacted by a physician's ability to build trusting relationships with patients. Identifying techniques for rapport building is important for promoting patient-physician collaboration and improved patient outcomes. This study sought to characterize the approaches highly skilled primary care physicians (PCPs) use to effectively connect with diverse patients.Using an inductive thematic analysis approach, we analyzed semi-structured interview transcripts with 10 PCPs identified by leadership and/or colleagues for having exceptional patient communication skills. PCPs practiced in 3 diverse clinic settings: (1) academic medical center, (2) Veterans Affairs clinic, and (3) safety-net community clinic.The thematic analysis yielded 5 themes that enable physicians to establish connections with patients: Respect for the Patient, Engaged Curiosity, Focused Listening, Mutual Participation, and Self-Awareness. Underlying all of these themes was a quality of authenticity, or a state of symmetry between one's internal experience and external words and actions. Adopting these communication techniques while allowing for adaptability in order to remain authentic in one's interactions with patients may facilitate improved connection and trust with patients. Encouraging physician authenticity in the patient-physician relationship supports a shift toward relationship-centered care. Additional medical education training is needed to facilitate authentic connection between physicians and patients.

    View details for DOI 10.1177/21501319231225996

    View details for PubMedID 38281122

  • A New Equilibrium for Telemedicine: Prevalence of In-Person, Video-Based, and Telephone-Based Care in the Veterans Health Administration, 2019-2023. Annals of internal medicine Ferguson, J. M., Wray, C. M., Van Campen, J., Zulman, D. M. 2024

    View details for DOI 10.7326/M23-2644

    View details for PubMedID 38252945

  • Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease. Journal of general internal medicine Tisdale, R., Der-Martirosian, C., Yoo, C., Chu, K., Zulman, D., Leung, L. 2024


    BACKGROUND: Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered.OBJECTIVE: Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension.DESIGN: Retrospective cohort study.PATIENTS: Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years.MAIN MEASURES: The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering.KEY RESULTS: Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06).CONCLUSIONS: Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

    View details for DOI 10.1007/s11606-023-08475-y

    View details for PubMedID 38252244

  • Research Priorities to Expand Virtual Care Access for Patients in the Veterans Affairs Health Care System. Journal of general internal medicine Wray, C. M., Myers, U., Slightam, C., Dardashti, N., Heyworth, L., Lewinski, A., Kaboli, P., Edes, T., Trueman, K., Zulman, D. M. 2024


    The rapid expansion of virtual care is driving demand for equitable, high-quality access to technologies that are required to utilize these services. While the Department of Veterans Affairs (VA) is seen as a national leader in the implementation of telehealth, there remain gaps in evidence about the most promising strategies to expand access to virtual care. To address these gaps, in 2022, the VA's Health Services Research and Development service and Office of Connected Care held a "state-of-the-art" (SOTA) conference to develop research priorities for advancing the science, clinical practice, and implementation of virtual care. One workgroup within the SOTA focused on access to virtual care and addressed three questions: (1) Based on the existing evidence about barriers that impede virtual care access in digitally vulnerable populations, what additional research is needed to understand these factors? (2) Based on the existing evidence about digital inclusion strategies, what additional research is needed to identify the most promising strategies? and (3) What additional research beyond barriers and strategies is needed to address disparities in virtual care access? Here, we report on the workgroup's discussions and recommendations for future research to improve and optimize access to virtual care. Effective implementation of these recommendations will require collaboration among VA operational leadership, researchers, Human Factors Engineering experts and front-line clinicians as they develop, implement, and evaluate the spread of virtual care access strategies.

    View details for DOI 10.1007/s11606-023-08463-2

    View details for PubMedID 38252237

  • Meeting high-risk patient pain care needs through intensive primary care: a secondary analysis. BMJ open Giannitrapani, K. F., Holliday, J. R., McCaa, M. D., Stockdale, S., Bergman, A. A., Katz, M. L., Zulman, D. M., Rubenstein, L. V., Chang, E. T. 2024; 14 (1): e080748


    Chronic pain disproportionately affects medically and psychosocially complex patients, many of whom are at high risk of hospitalisation. Pain prevalence among high-risk patients, however, is unknown, and pain is seldom a focus for improving high-risk patient outcomes. Our objective is to (1) evaluate pain frequency in a high-risk patient population and (2) identify intensive management (IM) programme features that patients and providers perceive as important for promoting patient-centred pain care within primary care (PC)-based IM.Secondary observational analysis of quantitative and qualitative evaluation data from a multisite randomised PC-based IM programme for high-risk patients.Five integrated local Veterans Affairs (VA) healthcare systems within distinct VA administrative regions.Staff and high-risk PC patients in the VA.A multisite randomised PC-based IM programme for high-risk patients.(a) Pain prevalence based on VA electronic administrative data and (b) transcripts of interviews with IM staff and patients that mentioned pain.Most (70%, 2593/3723) high-risk patients had at least moderate pain. Over one-third (38%, 40/104) of the interviewees mentioned pain or pain care. There were 89 pain-related comments addressing IM impacts on pain care within the 40 interview transcripts. Patient-identified themes were that IM improved communication and responsiveness to pain. PC provider-identified themes were that IM improved workload and access to expertise. IM team member-identified themes were that IM improved pain care coordination, facilitated non-opioid pain management options and mitigated provider compassion fatigue. No negative IM impacts on pain care were mentioned.Pain is common among high-risk patients. Future IM evaluations should consider including a focus on pain and pain care, with attention to impacts on patients, PC providers and IM teams.

    View details for DOI 10.1136/bmjopen-2023-080748

    View details for PubMedID 38167288

  • Sociodemographic Differences in the Impacts of Video-Enabled Tablets on Psychotherapy Usage Among Veterans. Psychiatric services (Washington, D.C.) Gujral, K., Van Campen, J., Jacobs, J., Lo, J., Kimerling, R., Blonigen, D. M., Wagner, T. H., Zulman, D. M. 2023: appips20230134


    To examine potential health disparities due to a broad reliance on telehealth during the COVID-19 pandemic, the authors studied the impact of video-enabled tablets provided by the U.S. Department of Veterans Affairs (VA) on psychotherapy usage among rural versus urban, Black versus White, and female versus male veterans.Psychotherapy usage trends before and after onset of the COVID-19 pandemic were examined among veterans with at least one mental health visit in 2019 (63,764 tablet recipients and 1,414,636 nonrecipients). Adjusted difference-in-differences and event study analyses were conducted to compare psychotherapy usage among tablet recipients and nonrecipients (March 15, 2020-December 31, 2021) 10 months before and after tablet issuance. Analyses were stratified by rurality, sex, and race.Adjusted analyses demonstrated that tablet receipt was associated with increases in psychotherapy visit frequency in every patient group studied (rural, 27.4%; urban, 24.6%; women, 30.5%; men, 24.4%; Black, 20.8%; White, 28.1%), compared with visits before tablet receipt. Compared with men, women had statistically significant tablet-associated psychotherapy visit increases (video visits, 1.2 per year; all modalities, 1.0 per year).VA-issued tablets led to increased psychotherapy usage for all groups examined, with similar increases found for rural versus urban and Black versus White veterans and higher increases for women versus men. Eliminating barriers to Internet access or device ownership may improve mental health care access among underserved or historically disadvantaged populations. VA's tablet program offers insights to inform policy makers' and health systems' efforts to bridge the digital divide.

    View details for DOI 10.1176/

    View details for PubMedID 38088041

  • Overcoming Obstacles: Barriers to Virtual Care Use Among Video-Enabled Tablet Recipients in the Veterans Health Administration. Journal of general internal medicine Wray, C. M., Ferguson, J. M., Greene, L., Griffin, A., Van Campen, J., O'Shea, A. M., Slightam, C., Zulman, D. M. 2023


    INTRODUCTION: The Veterans Health Administration (VHA) distributes video-enabled tablets to individuals with barriers to accessing care. Data suggests that many tablets are under-used. We surveyed Veterans who received a tablet to identify barriers that are associated with lower use, and evaluated the impact of a telephone-based orientation call on reported barriers and future video use.METHODS: We used a national survey to assess for the presence of 13 barriers to accessing video-based care, and then calculated the prevalence of the barriers stratified by video care utilization in the 6 months after survey administration. We used multivariable modeling to examine the association between each barrier and video-based care use and evaluated whether a telephone-based orientation modified this association.RESULTS: The most prevalent patient-reported barriers to video-based care were not knowing how to schedule a visit, prior video care being rescheduled/canceled, and past problems using video care. Following adjustment, individuals who reported vision or hearing difficulties and those who reported that video care does not provide high-quality care had a 19% and 12% lower probability of future video care use, respectively. Individuals who reported no interest in video care, or did not know how to schedule a video care visit, had an 11% and 10% lower probability of being a video care user, respectively. A telephone-based orientation following device receipt did not improve the probability of being a video care user.DISCUSSION: Barriers to engaging in virtual care persist despite access to video-enabled devices. Targeted interventions beyond telephone-based orientation are needed to facilitate adoption and engagement in video visits.

    View details for DOI 10.1007/s11606-023-08468-x

    View details for PubMedID 37914909

  • Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients. Health services research Maciejewski, M. L., Greene, L., Grubber, J. M., Blalock, D. V., Jacobs, J., Rao, M., Zulman, D. M., Smith, V. A. 2023


    Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death.Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models.Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures.In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.

    View details for DOI 10.1111/1475-6773.14243

    View details for PubMedID 37767603

  • Patterns and predictors of mental health service use among older veterans with alcohol use disorder who received a video-enabled tablet. Aging & mental health Alfaro, A. J., Greene, L., Van Campen, J., Zulman, D. M., Gould, C. E., Blonigen, D. M. 2023: 1-7


    Objectives: Video-based telehealth may expand access to mental health services among older veterans with alcohol use disorder (AUD). We examined the modalities through which mental health services were rendered, and predictors of video visits before and after video-enabled tablet receipt from the Veterans Health Administration.Method: 11,210 veterans aged 60 or older with a diagnosis of AUD who received a tablet between 1 April 2020 and 25 October 2021 were identified. The electronic health record was used to characterized encounters by modality of mental health care delivery in the sixmonths pre/post tablet receipt. Logistic regression examined predictors of a video visit for mental health.Results: Phone was the most common modality; however, the proportion of video encounters increased from 8.7% to 26.2% after tablet receipt. Individuals who were older, male, and had more physical health conditions, were less likely to have a video visit. Individuals who were married, resided in urban areas, had a history of housing instability, and had more mental health conditions, were more likely to have a video visit.Conclusion: Video-enabled tablets may help older adults with AUD overcome access barriers to mental health services, although targeted support for certain groups may be necessary.

    View details for DOI 10.1080/13607863.2023.2253448

    View details for PubMedID 37723897

  • Building trust and partnership with Black pediatric patients and their families: A scoping review. Academic pediatrics Garcia, R. S., Hollis, T., Baratta, J., King, Z., Faulks, M., Ricketts, M., Brown-Johnson, C., Shankar, M., Guerin, A., Wong, C., Zulman, D. M., Floyd, B. D. 2023


    Systemic racism embedded within the U.S. healthcare system results in disproportionately worse health outcomes for Black pediatric patients and their families/caregivers. One meaningful mechanism through which these health disparities persist is through discriminatory treatment and anti-Black bias from clinicians. Strengthening care provided to Black pediatric patients and their families/caregivers requires that clinicians adopt culturally tailored communication strategies that promote health equity and counter racism. We conducted a scoping review of evidence-based communication practices in the medical literature that improve care for Black pediatric patients. We mapped the specific practices to the Presence 5 for Racial Justice framework and identified cross-cutting themes to describe practices across the five domains. There are three cross-cutting themes that underlie the recommended practices: (1) promote unbiased implementation of clinician communication strategies (e.g., providing equitable recommendations for preventive care); (2) tailor care to Black pediatric patients (e.g., explore the importance of the family unit); and (3) address racism experienced by Black pediatric patients and their families/caregivers (e.g., acknowledge any previous negative experiences with the healthcare system). This review highlights communication practices that clinicians can adopt to build trusting relationships, empower Black families, and promote racial justice in clinical care. Future opportunities include expanding to system level change and validating these practices with patients and clinicians.

    View details for DOI 10.1016/j.acap.2023.08.016

    View details for PubMedID 37659602

  • Types of Engagement Strategies to Engage High-Risk Patients in VA. Journal of general internal medicine Bergman, A. A., Stockdale, S. E., Zulman, D. M., Katz, M. L., Asch, S. M., Chang, E. T. 2023


    Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging.To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program.We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach.The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change.We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

    View details for DOI 10.1007/s11606-023-08336-8

    View details for PubMedID 37620722

    View details for PubMedCentralID 4401870

  • DISPARITIES IN VIDEO CARE USE AMONG VETERANS WITH CARDIOVASCULAR DISEASE Tisdale, R. L., Der-Martirosian, C., Yoo, C., Chu, K., Zulman, D., Leung, L. B. SPRINGER. 2023: S173
  • Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans. Journal of general internal medicine Rao, M., Greene, L., Nelson, K., Maciejewski, M. L., Zulman, D. M. 2023


    Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services.To study associations between social risks and primary care utilization among patients with medical complexity.Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion.Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death.Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter.Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of  ≥ 1 social work encounter.We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.

    View details for DOI 10.1007/s11606-023-08269-2

    View details for PubMedID 37369890

    View details for PubMedCentralID 8254038

  • Adapting a Telephone-Based, Dyadic Self-management Program to Be Delivered Over the Web: Methodology and Usability Testing. JMIR formative research Trivedi, R., Hirayama, S. K., Risbud, R., Suresh, M., Humber, M. B., Butler, K., Razze, A., Timko, C., Nelson, K., Zulman, D. M., Asch, S. M., Humphreys, K., Piette, J. D. 2023; 7: e43903


    The COVID-19 pandemic has amplified the need for web-based behavioral interventions to support individuals who are diagnosed with chronic conditions and their informal caregivers. However, most interventions focus on patient outcomes. Dyadic technology-enabled interventions that simultaneously improve outcomes for patients and caregivers are needed.This study aimed to describe the methodology used to adapt a telephone-based, facilitated, and dyadic self-management program called Self-care Using Collaborative Coping Enhancement in Diseases (SUCCEED) into a self-guided, web-based version (web-SUCCEED) and to conduct usability testing for web-SUCCEED.We developed web-SUCCEED in 6 steps: ideation-determine the intervention content areas; prototyping-develop the wireframes, illustrating the look and feel of the website; prototype refinement via feedback from focus groups; finalizing the module content; programming web-SUCCEED; and usability testing. A diverse team of stakeholders including content experts, web designers, patients, and caregivers provided input at various stages of development. Costs, including full-time equivalent employee, were summarized.At the ideation stage, we determined the content of web-SUCCEED based on feedback from the program's original pilot study. At the prototyping stage, the principal investigator and web designers iteratively developed prototypes that included inclusive design elements (eg, large font size). Feedback about these prototypes was elicited through 2 focus groups of veterans with chronic conditions (n=13). Rapid thematic analysis identified two themes: (1) web-based interventions can be useful for many but should include ways to connect with other users and (2) prototypes were sufficient to elicit feedback about the esthetics, but a live website allowing for continual feedback and updating would be better. Focus group feedback was incorporated into building a functional website. In parallel, the content experts worked in small groups to adapt SUCCEED's content, so that it could be delivered in a didactic, self-guided format. Usability testing was completed by veterans (8/16, 50%) and caregivers (8/16, 50%). Veterans and caregivers gave web-SUCCEED high usability scores, noting that it was easy to understand, easy to use, and not overly burdensome. Notable negative feedback included "slightly agreeing" that the site was confusing and awkward. All veterans (8/8, 100%) agreed that they would choose this type of program in the future to access an intervention that aims to improve their health. Developing and maintaining the software and hosting together cost approximately US $100,000, excluding salary and fringe benefits for project personnel (steps 1-3: US $25,000; steps 4-6: US $75,000).Adapting an existing, facilitated self-management support program for delivery via the web is feasible, and such programs can remotely deliver content. Input from a multidisciplinary team of experts and stakeholders can ensure the program's success. Those interested in adapting programs should have a realistic estimate of the budget and staffing requirements.

    View details for DOI 10.2196/43903

    View details for PubMedID 37327057

  • Impact of VA's video telehealth tablets on substance use disorder care during the COVID-19 pandemic. Journal of substance use and addiction treatment Gujral, K., Van Campen, J., Jacobs, J., Kimerling, R., Zulman, D. M., Blonigen, D. 2023: 209067


    BACKGROUND: Telehealth has the potential to improve health care access for patients but it has been underused and understudied for examining patients with substance use disorders (SUD). VA began distributing video-enabled tablets to veterans with access barriers in 2016 to facilitate participation in home-based telehealth and expanded this program in 2020 due to the coronavirus COVID-19 pandemic.OBJECTIVE: Examine the impact of VA's video-enabled telehealth tablets on mental health services for patients diagnosed with SUD.METHODS: This study included VA patients who had ≥1 mental health visit in the calendar year 2019 and a documented diagnosis of SUD. Using difference-in-differences and event study designs, we compared outcomes for SUD-diagnosed patients who received a video-enabled tablet from VA between March 15th, 2020 and December 31st, 2021 and SUD-diagnosed patients who never received VA tablets, 10 months before and after tablet-issuance. Outcomes included monthly frequency of SUD psychotherapy visits, SUD specialty group therapy visits and SUD specialty individual outpatient visits. We examined changes in video visits and changes in visits across all modalities of care (video, phone, and in-person). Regression models adjusted for several covariates such as age, sex, rurality, race, ethnicity, physical and mental health chronic conditions, and broadband coverage in patients' residential zip-code.RESULTS: The cohort included 21,684 SUD-diagnosed tablet-recipients and 267,873 SUD-diagnosed non-recipients. VA's video-enabled tablets were associated with increases in video visits for SUD psychotherapy (+3.5 visits/year), SUD group therapy (+2.1 visits/year) and SUD individual outpatient visits (+1 visit/year), translating to increases in visits across all modalities (in-person, phone and video): increase of 18 % for SUD psychotherapy (+1.9 visits/year), 10 % for SUD specialty group therapy (+0.5 visit/year), and 4 % for SUD specialty individual outpatient treatment (+0.5 visit/year).CONCLUSIONS: VA's distribution of video-enabled tablets during the COVID-19 pandemic were associated with higher engagement with video-based services for SUD care among patients diagnosed with SUD, translating to modest increases in total visits across in-person, phone and video modalities. Distribution of video-enabled devices can offer patients critical continuity of SUD therapy, particularly in scenarios where they have heightened barriers to in-person care.

    View details for DOI 10.1016/j.josat.2023.209067

    View details for PubMedID 37164153

  • Clinical Validity of the PROMIS Healthcare Engagement 8-Item Short Form. Journal of general internal medicine Kimerling, R., Zulman, D. M., Lewis, E. T., Schalet, B. D., Reise, S. P., Tamayo, G. C. 2023


    Healthcare engagement is a key measurement target for value-based healthcare, but a reliable and valid patient-reported measure has not yet been widely adopted.To assess the validity of a newly developed patient-reported measure of healthcare engagement, the 8-item PROMIS Healthcare Engagement (PHE-8a).Prospective cohort study of the association between healthcare engagement and quality of care over 1 year. We fit mixed effects models of quality indicators as a function of engagement scores, adjusting for age, race/ethnicity, rural residence, and risk scores.National stratified random sample of 9552 Veterans receiving Veterans Health Administration care for chronic conditions (hypertension, diabetes) or mental health conditions (depression, post-traumatic stress disorder).Patient experience: Consumer Assessment of Health Plans and Systems communication and self-management support composites; no-show rates for primary care and mental health appointments; use of patient portal My HealtheVet; and Healthcare Effectiveness Data and Information Set electronic quality measures: HbA1c poor control, controlling high blood pressure, and hyperlipidemia therapy adherence.Higher engagement scores were associated with better healthcare quality across all outcomes, with each 5-point increase (1/2 standard deviation) in engagement scores associated with statistically significant and clinically meaningful gains in quality. Across the continuum of low to high engagement scores, we observed a concomitant reduction in primary care no-show rates of 37% and 24% for mental health clinics; an increased likelihood of My HealtheVet use of 15.4%; and a decreased likelihood of poor diabetes control of 44%.The PHE-8a is a brief, reliable, and valid patient-reported measure of healthcare engagement. These results confirm previously untested hypotheses that patient engagement can promote healthcare quality.

    View details for DOI 10.1007/s11606-022-07992-6

    View details for PubMedID 37118561

    View details for PubMedCentralID 6407348

  • Opportunities to Enhance the Implementation of Veterans Affairs Video-Based Care: Qualitative Perspectives of Providers from Diverse Specialties. Journal of medical Internet research Slightam, C., Wray, C., Tisdale, R. L., Zulman, D. M., Gray, C. 2023; 25: e43314


    Increasing the adoption of digital care tools, including video visits, is a long-term goal for the US Department of Veterans Affairs (VA). While previous work has highlighted patient-specific barriers to the use of video visits, few have examined how clinicians view such barriers and how they have overcome them during the rapid uptake of web-based care.This study sought input from providers, given their role as critical participants in video visit implementation, to qualitatively describe successful strategies providers used to adapt their practices to a web-based care setting.We conducted interviews with 28 VA providers (physicians and nurse practitioners) from 4 specialties that represent diverse clinical services: primary care (n=11), cardiology (n=7), palliative care (n=5), and spinal cord injury (n=5). All interviews were audio recorded and transcribed, and transcripts were reviewed and coded according to an iteratively created codebook. To identify themes, codes were grouped together into categories, and participant comments were reviewed for repetition and emphasis on specific points. Finally, themes were mapped to Expert Recommendations for Implementing Change (ERIC) strategies to identify evidence-based opportunities to support video visit uptake in the VA.Interviewees were mostly female (57%, 16/28), with an average age of 49 years and with 2-20 years of experience working in the VA across 16 unique VA facilities. Most providers (82%, 23/28) worked in urban facilities. Many interviewees (78%, 22/28) had some experience with video visits prior to the COVID-19 pandemic, though a majority (61%, 17/28) had conducted fewer than 50 video visits in the quarter prior to recruitment. We identified four primary themes related to how providers adapt their practices to a web-based care setting: (1) peer-based learning and support improved providers' perceived value of and confidence in video visits, (2) providers developed new and refined existing communication and clinical skills to optimize video visits, (3) providers saw opportunities to revisit and refine team roles to optimize the value of video visits for their care teams, and (4) implementing and sustaining web-based care requires institutional and organizational support. We identified several ERIC implementation strategies to support the use of video visits across the individual-, clinic-, and system-levels that correspond to these themes: (1) individual-level strategies include the development of educational materials and conducting education meetings, (2) clinic-level strategies include identifying champions and revising workflows and professional roles, and (3) system-level strategies include altering incentive structures, preparing implementation blueprints, developing and implementing tools for quality monitoring, and involving executive leadership to encourage adoption.This work highlights strategies to support video visits that align with established ERIC implementation constructs, which can be used by health care systems to improve video visit implementation.

    View details for DOI 10.2196/43314

    View details for PubMedID 37093642

  • Moving beyond inquiry: a secondary qualitative analysis on promoting racial justice in clinical care. BMC medical education Kyerematen, B., Garcia, R., Cox, J., Zulman, D. M., Shankar, M. 2023; 23 (1): 180


    Anti-Black racism is prevalent in medicine, and anti-racism training is needed in medical education. One such training is the Presence 5 for Racial Justice (P5RJ) Curriculum which covers evidence-based anti-racism communication strategies that promote health equity for Black patients. The P5RJ Curriculum was developed using feedback from clinicians and trainees with diversity, equity, and inclusion (DEI) experience. In this study, we identify themes in recommended anti-racism language and phrases that surveyed clinicians and trainees use to promote racial justice and health equity in clinical care for Black patients.Secondary analysis of survey responses to identify themes in qualitative data.Survey responses of specific phrases for anti-racism communication based on P5RJ Curriculum feedback.N = 50 respondents (27 clinicians, 17 medical trainees, 6 unreported) recruited through convenience sampling and listservs of clinicians with DEI experience. An inductive qualitative analysis was performed on survey responses to identify emerging themes.Emerging themes from survey responses reflected four communication practices: "Inquiry" was the predominant practice (59%), followed by "Empathy" (25%), "Statements of Allyship" (9%), and "Self-Accountability" (8%).Inquiry and empathy may be predominant communication practices when addressing anti-Black racism in medicine. There is an opportunity to expand anti-racism communication tools with statements of self-accountability and allyship. Future research is necessary to analyze the patient voice on clinician communication practices that promote anti-racism in clinical care.

    View details for DOI 10.1186/s12909-023-04131-5

    View details for PubMedID 36959597

    View details for PubMedCentralID PMC10035470

  • Distinct Health Care Use Patterns of Patients With Chronic Gastrointestinal Diseases AMERICAN JOURNAL OF MANAGED CARE Cohen-Mekelburg, S., Greene, L., Berinstein, J., Waljee, A. K., Hofer, T. P., Saini, S. D., Zulman, D. M. 2023; 29 (3): E71-+


    Patients with complex chronic conditions have varying multidisciplinary care needs and utilization patterns, which limit the effectiveness of initiatives designed to improve continuity of care (COC) and reduce utilization. Our objective was to categorize patients with complex chronic conditions into distinct groups by pattern of outpatient care use and COC to tailor interventions.Observational cohort study from 2014 to 2015.We identified patients whose 1-year hospitalization risk was in at least the 90th percentile in 2014 who had a chronic gastrointestinal disease (cirrhosis, inflammatory bowel disease, chronic pancreatitis) as case examples of complex chronic disease. We described frequency of office visits, number of outpatient providers, and 2 COC measures (usual provider of care, Bice-Boxerman COC indices) over 12 months. We used latent profile analysis, a statistical method for identifying distinct subgroups, to categorize patients based on overall, primary care, gastroenterology, and mental health continuity patterns.The 26,751 veterans in the cohort had a mean (SD) of 13.3 (8.6) office visits and 7.2 (3.8) providers in 2014. Patients were classified into 5 subgroups: (1) high gastroenterology-specific COC with mental health use; (2) high gastroenterology-specific COC without mental health use; (3) high overall utilization with mental health use; (4) low overall COC with mental health use; and (5) low overall COC without mental health use. These groups varied in their sociodemographic characteristics and risk for hospitalization, emergency department use, and mortality.Patients at high risk for health care utilization with specialty care needs can be grouped by varying propensity for health care continuity patterns.

    View details for DOI 10.37765/ajmc.2023.89332

    View details for Web of Science ID 000957510100001

    View details for PubMedID 36947019

  • Incorporating TechQuity in Virtual Care Within the Veterans Health Administration: Identifying Future Research and Operations Priorities. Journal of general internal medicine Walsh, C., Sullivan, C., Bosworth, H. B., Wilson, S., Gierisch, J. M., Goodwin, K. B., Mccant, F., Hoenig, H., Heyworth, L., Zulman, D. M., Turvey, C., Moy, E., Lewinski, A. A. 2023


    The Covid-19 pandemic dramatically changed healthcare delivery, driving rapid expansion of synchronous (i.e., real-time) audio-only and video telehealth, otherwise known as virtual care. Yet evidence describes significant inequities in virtual care utilization, with certain populations more dependent on audio-only virtual care than video-based care. Research is needed to inform virtual care policies and processes to counteract current inequities in access and health outcomes.Given the importance of incorporating equity into virtual care within the Veterans Health Administration (VHA), we convened a Think Tank to identify priorities for future research and virtual care operations focused on achieving equitable implementation of virtual care within the VHA.We used participatory activities to engage clinicians, researchers, and operational partners from across the VHA to develop priorities for equitable implementation of virtual care. We refined priorities through group discussion and force-ranked prioritization and outlined next steps for selected priorities.Think Tank participants included 43 individuals from the VHA who represented diverse geographical regions, offices, and backgrounds. Attendees self-identified their associations primarily as operations (n = 9), research (n = 28), or both (n = 6). We identified an initial list of 63 potential priorities for future research and virtual care operations. Following discussion, we narrowed the list to four priority areas: (1) measure inequities in virtual care, (2) address emerging inequities in virtual care, (3) deploy virtual care equitably to accommodate differently abled veterans, and (4) measure and address potential adverse consequences of expanded virtual care. We discuss related information, data, key partners, and outline potential next steps.This Think Tank of research and operational partners from across the VHA identified promising opportunities to incorporate equity into the design and implementation of virtual care. Although much work remains, the priorities identified represent important steps toward achieving this vital goal.

    View details for DOI 10.1007/s11606-023-08029-2

    View details for PubMedID 36650326

  • VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 -Implications for Veterans with prior mental health needs. PloS one Gujral, K., Bahraini, N., Brenner, L. A., Van Campen, J., Zulman, D. M., Illarmo, S., Wagner, T. H. 2023; 18 (4): e0283633


    IMPORTANCE: United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas.OBJECTIVE: To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019.METHODS: VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation.MEASURES: Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR).RESULTS: 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9.CONCLUSION: VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.

    View details for DOI 10.1371/journal.pone.0283633

    View details for PubMedID 37040367

  • Teaching Anti-Racism in the Clinical Environment: The Five-Minute Moment for Racial Justice in Healthcare: Teaching anti-racism. The American journal of medicine Wang, S. X., Chi, K., Shankar, M., Israni, S. T., Verghese, A., Zulman, D. M. 2022


    Dismantling racism in health care demands that medical education promote racial justice throughout all stages of medical training. However, racial bias can be fostered unintentionally, influencing the way we make decisions as clinicians with downstream effects on patient health and health equity. The development of any anti-racism curriculum in medicine requires the ability to identify racial bias in practices we have not previously recognized as explicitly racist or unjust. This has limited the creation and delivery of effective antiracism education in healthcare.

    View details for DOI 10.1016/j.amjmed.2022.12.014

    View details for PubMedID 36566895

  • Increasing Use of Video Telehealth Among Veterans Experiencing Homelessness with Substance Use Disorder: Design of A Peer-Led Intervention. Journal of technology in behavioral science Garvin, L. A., Greenan, M. A., Edelman, E. J., Slightam, C., McInnes, D. K., Zulman, D. M. 2022: 1-12


    Telehealth offers promising opportunities, but also challenges, for veterans experiencing homelessness - during the COVID-19 pandemic and beyond. Recent research found low utilization of clinical video visits among homeless veterans receiving a VA tablet, and having a substance use disorder (SUD) further reduced visit likelihood. Hence, this study sought to identify unique barriers to telehealth use among veterans experiencing homelessness with a SUD and design an intervention to promote adoption. This qualitative study was guided by the Unified Theory of Acceptance and Use of Technology (UTAUT) model. The study's three phases included veteran interviews (N=28) to identify barriers and facilitators to video telehealth use and propose intervention candidates, a provider expert panel to obtain feedback on interventions, and a focus group with veterans to complete the intervention. Finally, a prototype was designed using the intervention mapping approach. Veteran interviews revealed that barriers to video telehealth included complex physical and mental health issues, lack of digital literacy, and insufficient technical support. Together, veterans and experts proposed five intervention candidates. In the end, a veteran focus group combined two candidates, peer-led digital training and motivational interviewing. Intervention mapping was used to design a "stepped care" intervention that trains and activates veterans at all skill levels. This study demonstrates how inclusion of expert and veteran views led to development of a novel intervention to support and sustain video telehealth use among veterans experiencing homeless with SUD.

    View details for DOI 10.1007/s41347-022-00290-2

    View details for PubMedID 36573210

  • Overcoming Access Barriers for Veterans: A Cohort Study of the Distribution and Use of VA's Video-Enabled Tablets Before and During the COVID-19 Pandemic. Journal of medical Internet research Dhanani, Z., Ferguson, J. M., Van Campen, J., Slightam, C., Jacobs, J. C., Heyworth, L., Zulman, D. 2022


    BACKGROUND: During the COVID-19 pandemic, as health care services shifted to virtual modalities for patient and provider safety, the Veterans Affairs (VA) Office of Connected Care widely expanded its video-enabled tablet program to bridge digital divides for Veterans with limited virtual care access.OBJECTIVE: To characterize Veterans who received and used U.S. Department of Veterans Affairs (VA)-issued video-enabled tablets before versus during the COVID-19 pandemic.METHODS: We compared sociodemographic and clinical characteristics of Veterans who received VA-issued tablets during six-month pre-pandemic and pandemic periods (i.e., 3/11/2019-9/10/19 and 3/11/20-9/10/20). Then, we examined characteristics associated with video visit utilization for primary and mental health care within six months after tablet shipment, stratifying models by timing of tablet receipt.RESULTS: There was a nearly six-fold increase in the number of Veterans who received tablets in the pandemic vs pre-pandemic study periods (N= 336,107 vs 6,784, respectively). Compared to pre-pandemic, tablet recipients during the pandemic were more likely to be older (mean 64 vs. 59 years), urban-dwelling (68% vs. 56%) and have a history of housing instability (24% vs. 15%). Pandemic recipients were more likely to utilize video care (69% vs. 54%) and did so more frequently (5.6 vs. 2.3 average encounters) within six months of tablet receipt. In adjusted models, pandemic and pre-pandemic video care users were significantly more likely to be younger, stably housed, and have a mental health condition than non-users.CONCLUSIONS: Although the COVID-19 pandemic led to increased distribution of VA-issued tablets to Veterans with complex clinical and social needs, tablet recipients who were older or unstably housed remained less likely to have a video visit. The VA's tablet distribution program expanded access to video-enabled devices, but interventions are needed to bridge disparities in video visit utilization among device recipients.

    View details for DOI 10.2196/42563

    View details for PubMedID 36630650

  • Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic. JAMIA open Tisdale, R. L., Ferguson, J., Van Campen, J., Greene, L., Sandhu, A. T., Heidenreich, P. A., Zulman, D. M. 2022; 5 (4): ooac103


    Objective: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic.Materials and Methods: Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019-March 10, 2020, with follow-up January 1, 2019-March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model.Results: 416587 Veterans with 1689595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75-0.86; for highly rural residents 0.77, 95% CI 0.68-0.87; for low-income status 0.94, 95% CI 0.89-0.98; for homeless Veterans 0.85, 95% CI 0.80-0.92).Conclusion: The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology care.

    View details for DOI 10.1093/jamiaopen/ooac103

    View details for PubMedID 36531138

  • Variation in Initial and Continued use of Primary, Mental Health, and Specialty Video Care among Veterans. Health services research Ferguson, J. M., Wray, C. M., Jacobs, J., Greene, L., Wagner, T. H., Odden, M. C., Freese, J., Van Campen, J., Asch, S. M., Heyworth, L., Zulman, D. M. 2022


    OBJECTIVE: To identify which Veteran populations are routinely accessing video-based care.DATA SOURCES AND STUDY SETTING: National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021 STUDY DESIGN: This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021.DATA COLLECTION: Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study.PRINCIPAL FINDINGS: Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations.CONCLUSIONS: Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.

    View details for DOI 10.1111/1475-6773.14098

    View details for PubMedID 36345235

  • Association Between Patient-reported Social, Behavioral, and Health Factors and Emergency Department Visits in High-Risk VA Patients. Health services research Greene, L., Maciejewski, M. L., Grubber, J., Smith, V. A., Blalock, D. V., Zulman, D. M. 2022


    RESEARCH OBJECTIVE: To identify patient-reported social risk, behavioral, and health factors associated with emergency department (ED) utilization in high-risk Veterans Affairs (VA) patients.DATA SOURCES: Patient survey, VA, Medicare data.STUDY DESIGN: Prospective cohort study using multivariable logistic regression to identify patient-reported factors associated with all-cause and ambulatory care sensitive condition (ACSC)-related ED visits among VA patients at high-risk for hospitalization or death DATA EXTRACTION METHODS: Patient-reported measures derived from a 2018 survey sent to 10,000 VA patients; clinical and demographic characteristics derived from VA data; ED visits derived from VA and Medicare claims.PRINCIPAL FINDINGS: Among 4,680 survey respondents, 52.5% and 16.3% experienced an all-cause or ACSC-related ED visit in the following year, respectively. An ED visit was more likely among individuals with functional status limitations (6.0% points (Confidence Interval (CI) 0.017-0.103)) and transportation barriers (5.2% points (CI 0.005-0.099)). An ACSC-related ED visit was more likely among individuals with functional status limitations (3.2% points (CI 0.003-0.062)) and self-rated poorer health (7.4% points (CI 0.030-0.119) poor; 6.2% points (CI 0.029-0.096) fair; 4.1% points (CI 0.009-0.073) good; compared with excellent/very good).CONCLUSIONS: Patient-reported factors not present in most electronic health records were significantly associated with future ED visits in high-risk VA patients. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/1475-6773.14094

    View details for PubMedID 36310448

  • Tablet distribution to veterans: an opportunity to increase patient portal adoption and use. Journal of the American Medical Informatics Association : JAMIA Griffin, A. C., Troszak, L. K., Van Campen, J., Midboe, A. M., Zulman, D. M. 2022


    OBJECTIVE: Examine whether distribution of tablets to patients with access barriers influences their adoption and use of patient portals.MATERIALS AND METHODS: This retrospective cohort study included Veterans Affairs (VA) patients (n=28 659) who received a VA-issued tablet between November 1, 2020 and April 30, 2021. Tablets included an app for VA's My HealtheVet (MHV) portal. Veterans were grouped into 3 MHV baseline user types (non-users, inactive users, and active users) based on MHV registration status and feature use pre-tablet receipt. Three multivariable models were estimated to examine the factors predicting (1) MHV registration among non-users, (2) any MHV feature use among inactive users, and (3) more MHV use among active users post-tablet receipt. Differences in feature use during the 6 months pre-/post-tablet were examined with McNemar chi-squared tests of proportions.RESULTS: In the 6 months post-tablet, 1298 (8%) non-users registered for MHV, 525 (24%) inactive users used at least one MHV feature, and 4234 (46%) active users increased feature use. Across veteran characteristics, there were differences in registration and feature use post-tablet, particularly among older adults and those without prior use of video visits (P<.01). Among active users, use of all features increased during the 6 months post-tablet, with the greatest differences in viewing prescription refills and scheduling appointments (P<.01).CONCLUSION: Providing patients who experience barriers to in-person care with a portal-enabled device supports engagement in health information and management tasks. Additional strategies are needed to promote registration and digital inclusion among inactive and non-users of portals.

    View details for DOI 10.1093/jamia/ocac195

    View details for PubMedID 36269168

  • Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care. JAMA network open Edwards, S. T., Greene, L., Chaudhary, C., Boothroyd, D., Kinosian, B., Zulman, D. M. 2022; 5 (9): e2230036


    Importance: Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients.Objective: To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death.Design, Setting, and Participants: This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022.Exposures: Two indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner.Main Outcomes and Measures: Emergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015.Results: Among 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n=3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]).Conclusions and Relevance: Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.

    View details for DOI 10.1001/jamanetworkopen.2022.30036

    View details for PubMedID 36066895

  • Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. Journal of general internal medicine Trivedi, R. B., Rossi, F. S., Javier, S. J., Greene, L., Singer, S. J., Vanneman, M. E., Goldstein, M., Zulman, D. M. 2022


    BACKGROUND: Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions.OBJECTIVE: To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions.DESIGN: Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data.PARTICIPANTS: 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization.MAIN OUTCOME AND MEASURES: The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care.KEY RESULTS: In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30).CONCLUSIONS: Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.

    View details for DOI 10.1007/s11606-022-07705-z

    View details for PubMedID 35869316

  • Factors Associated With Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients With Complex Needs. The Journal of ambulatory care management Stockdale, S. E., Rose, D. E., McClean, M., Rosland, A., Chang, E. T., Zulman, D. M., Stewart, G., Nelson, K. M. 2022; 45 (3): 171-181


    Using data from a Veterans Health Administration national primary care survey, this study identified the most highly rated tools and care approaches for patients with complex needs and how preferences varied by professional role, staffing, and training. Nurses were significantly more likely to rate most tools as very important as compared with primary care providers. Having a fully staffed team was also significantly associated with a very important rating on all tools. Nurses and fully staffed teams reported a greater likeliness to use most care approaches, and those with perceived need for training reporting a lower likeliness to use.

    View details for DOI 10.1097/JAC.0000000000000418

    View details for PubMedID 35612388

  • Crossing the digital divide: a veteran affairs program to distribute video-enabled devices to patients in a supportive housing program. JAMIA open Wray, C. M., Van Campen, J., Hu, J., Slightam, C., Heyworth, L., Zulman, D. M. 2022; 5 (2): ooac027


    Evaluate an initiative to distribute video-enabled tablets and cell phones to individuals enrolled in Veterans Health Affairs supportive housing program during the COVID-19 pandemic.In September 2020, individuals in the Veteran Health Affairs (VA) Housing and Urban Development-VA Supportive Housing (HUD-VASH) program were offered either a video-enabled tablet or cellphone to support their communication and health care engagement needs. We examined sociodemographic and clinical characteristics of device recipients, and compared engagement in in-person, telephone, and video-based visits (categorized as primary care, specialty care, rehabilitation, HUD-VASH, mental health care, and other) for 6 months prior to (March 1, 2020-August 31, 2020) and following (September 1, 2020-July 30, 2021) device receipt.In total, 5127 Veterans received either a tablet (n = 4454) or a cellphone (n = 673). Compared to the 6 months prior to device receipt, in the 6 months following receipt, in-person and video engagement increased by an average of 1.4 visits (8%) and 3.4 visits (125%), respectively, while telephone engagement decreased (-5.2 visits; -27%). Both tablet and cellphone recipients had increased in-person visits (+1.3 visits [8%] and +2.1 visits [13%], respectively); while tablet users had a substantially larger increase in video-based engagement (+3.2 visits [+110%] vs. +0.9 [+64%]). Similar trends were noted across all assessed types of care.Providing video-enabled devices to Veterans in a supportive housing program may facilitate engagement in health care.VA's device distribution program offers a model for expanding access to health-related technology and telemedicine to individuals in supportive housing programs.

    View details for DOI 10.1093/jamiaopen/ooac027

    View details for PubMedID 35991861

    View details for PubMedCentralID PMC9053098

  • The Presence 5 for Racial Justice Framework for Anti-Racist Communication with Black Patients. Health services research Brown-Johnson, C., Cox, J., Shankar, M., Baratta, J., De Leon, G., Garcia, R., Hollis, T., Verano, M., Henderson, K., Upchurch, M., Safaeinili, N., Shaw, J. G., Fortuna, R. J., Beverly, C., Walsh, M., Somerville, C. S., Haverfield, M., Israni, S. T., Verghese, A., Zulman, D. M. 2022


    To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care.Qualitative data (N=112 participants, August 2020 to March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY.This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care.Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n=36 Black patients; n=40 non-medical professionals and n=24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation.The emergent Presence 5 for Racial Justice (P5RJ) practices include: 1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; 2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with healthcare; 3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; 4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; 5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions.P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address their needs.

    View details for DOI 10.1111/1475-6773.14015

    View details for PubMedID 35765147

  • Crossing the digital divide: a veteran affairs program to distribute video-enabled devices to patients in a supportive housing program JAMIA OPEN Wray, C. M., Van Campen, J., Hu, J., Slightam, C., Heyworth, L., Zulman, D. M. 2022; 5 (2)
  • Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic. JAMA network open Gujral, K., Van Campen, J., Jacobs, J., Kimerling, R., Blonigen, D., Zulman, D. M. 2022; 5 (4): e226250


    Importance: Suicide rates are rising disproportionately in rural counties, a concerning pattern as the COVID-19 pandemic has intensified suicide risk factors in these regions and exacerbated barriers to mental health care access. Although telehealth has the potential to improve access to mental health care, telehealth's effectiveness for suicide-related outcomes remains relatively unknown.Objective: To evaluate the association between the escalated distribution of the US Department of Veterans Affairs' (VA's) video-enabled tablets during the COVID-19 pandemic and rural veterans' mental health service use and suicide-related outcomes.Design, Setting, and Participants: This retrospective cohort study included rural veterans who had at least 1 VA mental health care visit in calendar year 2019 and a subcohort of patients identified by the VA as high-risk for suicide. Event studies and difference-in-differences estimation were used to compare monthly mental health service utilization for patients who received VA tablets during COVID-19 with patients who were not issued tablets over 10 months before and after tablet shipment. Statistical analysis was performed from November 2021 to February 2022.Exposure: Receipt of a video-enabled tablet.Main Outcomes and Measures: Mental health service utilization outcomes included psychotherapy visits, medication management visits, and comprehensive suicide risk evaluations (CSREs) via video and total visits across all modalities (phone, video, and in-person). We also analyzed likelihood of emergency department (ED) visit, likelihood of suicide-related ED visit, and number of VA's suicide behavior and overdose reports (SBORs).Results: The study cohort included 13 180 rural tablet recipients (11 617 [88%] men; 2161 [16%] Black; 301 [2%] Hispanic; 10 644 [80%] White; mean [SD] age, 61.2 [13.4] years) and 458 611 nonrecipients (406 545 [89%] men; 59 875 [13%] Black or African American; 16 778 [4%] Hispanic; 384 630 [83%] White; mean [SD] age, 58.0 [15.8] years). Tablets were associated with increases of 1.8 psychotherapy visits per year (monthly coefficient, 0.15; 95% CI, 0.13-0.17), 3.5 video psychotherapy visits per year (monthly coefficient, 0.29; 95% CI, 0.27-0.31), 0.7 video medication management visits per year (monthly coefficient, 0.06; 95% CI, 0.055-0.062), and 0.02 video CSREs per year (monthly coefficient, 0.002; 95% CI, 0.002-0.002). Tablets were associated with an overall 20% reduction in the likelihood of an ED visit (proportion change, -0.012; 95% CI, -0.014 to -0.010), a 36% reduction in the likelihood of suicide-related ED visit (proportion change, -0.0017; 95% CI, -0.0023 to -0.0013), and a 22% reduction in the likelihood of suicide behavior as indicated by SBORs (monthly coefficient, -0.0011; 95% CI, -0.0016 to -0.0005). These associations persisted for the subcohort of rural veterans the VA identifies as high-risk for suicide.Conclusions and Relevance: This cohort study of rural US veterans with a history of mental health care use found that receipt of a video-enabled tablet was associated with increased use of mental health care via video, increased psychotherapy visits (across all modalities), and reduced suicide behavior and ED visits. These findings suggest that the VA and other health systems should consider leveraging video-enabled tablets for improving access to mental health care via telehealth and for preventing suicides among rural residents.

    View details for DOI 10.1001/jamanetworkopen.2022.6250

    View details for PubMedID 35385088

  • RCT of the effectiveness of stepped-care sleep therapy in general practice: The RESTING study protocol. Contemporary clinical trials Manber, R., Tully, I. A., Palaniappan, L., Kim, J. P., Simpson, N., Zulman, D. M., Goldhaber-Fiebert, J. D., Rangel, E., Dietch, J. R., Rosas, L. G. 2022: 106749


    Cognitive behavioral therapy for insomnia (CBT-I) is an effective, non-pharmacological intervention, designated by the American College of Physicians as the first-line treatment of insomnia disorder. The current randomized controlled study uses a Hybrid-Type-1 design to compare the effectiveness and implementation potential of two approaches to delivering CBT-I in primary care. One approach offers therapy to all patients through an automated, digital CBT-I program (ONLINE-ONLY). The other is a triaged STEPPED-CARE approach that uses a simple Decision Checklist to start patients in either digital or therapist-led treatment; patients making insufficient progress with digital treatment at 2 months are switched to therapist-led treatment. We will randomize 240 individuals (age 50 or older) with insomnia disorder to ONLINE-ONLY or STEPPED-CARE arms. The primary outcomes are insomnia severity and hypnotic medication use, assessed at baseline and at months 2, 4, 6, 9, and 12 after randomization. We hypothesize that STEPPED-CARE will be superior to ONLINE-ONLY in reducing insomnia severity and hypnotic use. We also aim to validate the Decision Checklist and explore moderators of outcome. Additionally, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will use mixed methods to obtain data on the potential for future dissemination and implementation of each approach. This triaged stepped-care approach has the potential to improve sleep, reduce use of hypnotic medications, promote safety, offer convenient access to treatment, and support dissemination of CBT-I to a large number of patients currently facing barriers to accessing treatment. Clinical trial registration:NCT03532282.

    View details for DOI 10.1016/j.cct.2022.106749

    View details for PubMedID 35367385

  • Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health services research Zulman, D. M., Greene, L., Slightam, C., Singer, S. J., Maciejewski, M. L., Goldstein, M. K., Vanneman, M. E., Yoon, J., Trivedi, R. B., Wagner, T., Asch, S. M., Boothroyd, D. 2022


    OBJECTIVE: To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.DATA SOURCES: Veterans Affairs (VA) and Medicare data.STUDY DESIGN: We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization.DATA EXTRACTION METHODS: We extracted data for 130,704 VA patients ≥65years old with a hospitalization risk ≥90th percentile and≥four outpatient visits in the baseline year.PRINCIPAL FINDINGS: Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI=1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).CONCLUSIONS: Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

    View details for DOI 10.1111/1475-6773.13956

    View details for PubMedID 35178702

  • Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization. Medicine Vanneman, M. E., Yoon, J., Singer, S. J., Wagner, T. H., Goldstein, M. K., Hu, J., Boothroyd, D., Greene, L., Zulman, D. M. 2022; 101 (7): e28864


    ABSTRACT: U.S. Veterans Affairs (VA) patients' multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans' use of non-VA care, including VA-purchased care ("Community Care") and Medicare.To examine the relationship between drive distance and time-key eligibility criteria for Community Care-and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients' drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05-1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.

    View details for DOI 10.1097/MD.0000000000028864

    View details for PubMedID 35363189

  • Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study. JAMA network open Shankar, M., Cox, J., Baratta, J., De Leon, G., Shaw, J. G., Israni, S. T., Zulman, D. M., Brown-Johnson, C. G. 2022; 5 (2): e2147835


    Importance: Overwhelming evidence that anti-Black racism is associated with health inequities is driving clinician demand for antiracism practices that promote health equity.Objective: To investigate how nonmedical professionals address personally mediated, institutional, and internalized racism and to adapt these practices for the clinical setting.Design, Setting, and Participants: Using an approach from human-centered design for this qualitative study, virtual qualitative interviews were conducted among 40 professionals from nonmedical fields to investigate antiracism practices used outside of medicine. Inductive thematic analysis was conducted to identify latent themes and practices that may be adaptable to health care, subsequently using an established theoretical framework describing levels of racism to interpret and organize themes. Convenience and purposive sampling was used to recruit participants via email, social media, and electronic flyers.Main Outcomes and Measures: Antiracism practices adapted to medicine.Results: Among 40 professionals from nonmedical fields, most were younger than age 40 years (23 individuals [57.5%]) and there were 20 (50.0%) women; there were 25 Black or African American individuals (62.5%); 4 East Asian, Southeast Asian, or South Asian individuals (10.0%); 3 individuals with Hispanic, Latinx, or Spanish origin (7.5%); and 3 White individuals. Participants described personally mediated, institutional, and internalized antiracism practices that may be adaptable to promote health equity for Black patients. Personally mediated antiracism practices included dialogue and humble inquiry, building trust, and allyship and shared humanity; clinicians may be able to adopt these practices by focusing on patient successes, avoiding stigmatizing language in the electronic health record, and using specific phrases to address racism in the moment. Institutional antiracism practices included education, representation, and mentorship; in the health care setting, clinics may be able to develop staff affiliate groups, focus on improving racial health equity outcomes, and conduct antiracism trainings. Internalized antiracism practices centered on authenticity; clinicians may be able to write positionality statements reflecting their identity and the expertise they bring to clinical encounters.Conclusions and Relevance: This study's findings suggest that antiracism practices from outside the health care sector may offer innovative strategies to promote health equity by addressing personally mediated, institutional, and internalized racism in clinical care.

    View details for DOI 10.1001/jamanetworkopen.2021.47835

    View details for PubMedID 35138395

  • Presence 5 for Racial Justice Workshop: Fostering Dialogue Across Medical Education to Disrupt Anti-Black Racism in Clinical Encounters. MedEdPORTAL : the journal of teaching and learning resources Shankar, M., Henderson, K., Garcia, R., Li, G., Titer, K., Acholonu, R. G., Essien, U. R., Brown-Johnson, C., Cox, J., Shaw, J. G., Haverfield, M. C., Taylor, K., Israni, S. T., Zulman, D. 2022; 18: 11227


    Introduction: Anti-Black racism has strong roots in American health care and medical education. While curricula on social determinants of health are increasingly common in medical training, curricula directly addressing anti-Black racism are limited. Existing frameworks like the Presence 5 framework for humanism in medicine can be adapted to develop a novel workshop that promotes anti-racism communication.Methods: We performed a literature review of anti-racism collections and categorized anti-racism communication practices using the Presence 5 framework to develop the Presence 5 for Racial Justice Workshop. Implementation included an introductory didactic, a small-group discussion, and a large-group debrief. Participants evaluated the workshop via an online survey, and we analyzed the resulting qualitative feedback.Results: A total of 17 participants took part in two workshops, with nine of the participants responding to the evaluation survey. Themes that emerged from survey responses included strengths of and improvements for the workshop structure (protected time for anti-racism discussion, dialogue between learners and faculty) and content (specific phrases and language, practicing self-reflection).Discussion: The workshop provides participants with a semistructured discussion around the five anti-racism communication practices. Barriers to implementation include incorporating the workshop into existing curricula and ensuring diverse learners. Barriers to evaluating the workshop include the low survey response rate. Recommendations to improve the workshop include using case-based discussion and varying the workshop structure according to institutional needs. Next steps include an implementation study to evaluate the acceptability, feasibility, and effectiveness of the workshop.

    View details for DOI 10.15766/mep_2374-8265.11227

    View details for PubMedID 35198729

  • Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients. Medical care research and review : MCRR Jacobs, J. C., Maciejeweski, M. L., Wagner, T. H., Van Houtven, C. H., Lo, J., Greene, L., Zulman, D. M. 1800: 10775587211062403


    This article examines the relative merit of augmenting an electronic health record (EHR)-derived predictive model of institutional long-term care (LTC) use with patient-reported measures not commonly found in EHRs. We used survey and administrative data from 3,478 high-risk Veterans aged ≥65 in the U.S. Department of Veterans Affairs, comparing a model based on a Veterans Health Administration (VA) geriatrics dashboard, a model with additional EHR-derived variables, and a model that added survey-based measures (i.e., activities of daily living [ADL] limitations, social support, and finances). Model performance was assessed via Akaike information criteria, C-statistics, sensitivity, and specificity. Age, a dementia diagnosis, Nosos risk score, social support, and ADL limitations were consistent predictors of institutional LTC use. Survey-based variables significantly improved model performance. Although demographic and clinical characteristics found in many EHRs are predictive of institutional LTC, patient-reported function and partnership status improve identification of patients who may benefit from home- and community-based services.

    View details for DOI 10.1177/10775587211062403

    View details for PubMedID 34906010

  • Clinical Outcome and Utilization Profiles Among Latent Groups of High-Risk Patients: Moving from Segmentation Towards Intervention. Journal of general internal medicine Hutchins, F., Thorpe, J., Maciejewski, M. L., Zhao, X., Daniels, K., Zhang, H., Zulman, D. M., Fihn, S., Vijan, S., Rosland, A. 2021


    BACKGROUND: The ability of latent class models to identify clinically distinct groups among high-risk patients has been demonstrated, but it is unclear how healthcare data can inform group-specific intervention design.OBJECTIVE: Examine how utilization patterns across latent groups of high-risk patients provide actionable information to guide group-specific intervention design.DESIGN: Cohort study using data from 2012 to 2015.PATIENTS: Participants were 934,787 patients receiving primary care in the Veterans Health Administration, with predicted probability of 12-month hospitalization in the top 10th percentile during 2014.MAIN MEASURES: Patients were assigned to latent groups via mixture-item response theory models based on 28 chronic conditions. We modeled odds of all-cause mortality, hospitalizations, and 30-day re-hospitalizations by group membership. Detailed outpatient and inpatient utilization patterns were compared between groups.KEY RESULTS: A total of 764,257 (81.8%) of patients were matched with a comorbidity group. Groups were characterized by substance use disorders (14.0% of patients assigned), cardiometabolic conditions (25.7%), mental health conditions (17.6%), pain/arthritis (19.1%), cancer (15.3%), and liver disease (8.3%). One-year mortality ranged from 2.7% in the Mental Health group to 14.9% in the Cancer group, compared to 8.5% overall. In adjusted models, group assignment predicted significantly different odds of each outcome. Groups differed in their utilization of multiple types of care. For example, patients in the Pain group had the highest utilization of in-person primary care, with a mean (SD) of 5.3 (5.0) visits in the year of follow-up, while the Substance Use Disorder group had the lowest, with 3.9 (4.1) visits. The Substance Use Disorder group also had the highest rates of using services for housing instability (25.1%), followed by the Liver group (10.1%).CONCLUSIONS: Latent groups of high-risk patients had distinct hospitalization and utilization profiles, despite having comparable levels of predicted baseline risk. Utilization profiles pointed towards system-specific care needs that could inform tailored interventions.

    View details for DOI 10.1007/s11606-021-07166-w

    View details for PubMedID 34731436

  • Using ethnographic methods to classify the human experience in medicine: a case study of the presence ontology. Journal of the American Medical Informatics Association : JAMIA Maitra, A., Kamdar, M. R., Zulman, D. M., Haverfield, M. C., Brown-Johnson, C., Schwartz, R., Israni, S. T., Verghese, A., Musen, M. A. 2021


    OBJECTIVE: Although social and environmental factors are central to provider-patient interactions, the data that reflect these factors can be incomplete, vague, and subjective. We sought to create a conceptual framework to describe and classify data about presence, the domain of interpersonal connection in medicine.METHODS: Our top-down approach for ontology development based on the concept of "relationality" included the following: 1) a broad survey of the social sciences literature and a systematic literature review of >20 000 articles around interpersonal connection in medicine, 2) relational ethnography of clinical encounters (n=5 pilot, 27 full), and 3) interviews about relational work with 40 medical and nonmedical professionals. We formalized the model using the Web Ontology Language in the Protege ontology editor. We iteratively evaluated and refined the Presence Ontology through manual expert review and automated annotation of literature.RESULTS AND DISCUSSION: The Presence Ontology facilitates the naming and classification of concepts that would otherwise be vague. Our model categorizes contributors to healthcare encounters and factors such as communication, emotions, tools, and environment. Ontology evaluation indicated that cognitive models (both patients' explanatory models and providers' caregiving approaches) influenced encounters and were subsequently incorporated. We show how ethnographic methods based in relationality can aid the representation of experiential concepts (eg, empathy, trust). Our ontology could support investigative methods to improve healthcare processes for both patients and healthcare providers, including annotation of videotaped encounters, development of clinical instruments to measure presence, or implementation of electronic health record-based reminders for providers.CONCLUSION: The Presence Ontology provides a model for using ethnographic approaches to classify interpersonal data.

    View details for DOI 10.1093/jamia/ocab091

    View details for PubMedID 34151988

  • Outcomes of a randomized quality improvement trial for high-risk Veterans in year two. Health services research Chang, E. T., Yoon, J., Esmaeili, A., Zulman, D. M., Ong, M. K., Stockdale, S. E., Jimenez, E. E., Chu, K., Atkins, D., Denietolis, A., Asch, S. M., PACT Intensive Management (PIM) Demonstration Sites, P. N. 2021


    OBJECTIVE: The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year.DATA SOURCES: VHA administrative data for five demonstration sites from August 2013 to March 2019.DATA SOURCES: Administrative data extracted from VHA's Corporate Data Warehouse.STUDY DESIGN: Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24months after randomization for PIM vs usual care using difference-in-differences.PRINCIPAL FINDINGS: Both PIM patients (n=1902) and usual care patients (n=1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p<0.05), but ED visits (p=0.45) and hospitalizations (p=0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference+$928/patient/year, p=0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p=0.97). Total mean health care costs were similar between the two groups during the second year (mean difference+$1479/patient/year, p=0.73).CONCLUSIONS: Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.

    View details for DOI 10.1111/1475-6773.13674

    View details for PubMedID 34145564

  • Use of Video Telehealth Tablets to Increase Access for Veterans Experiencing Homelessness. Journal of general internal medicine Garvin, L. A., Hu, J., Slightam, C., McInnes, D. K., Zulman, D. M. 2021


    BACKGROUND: Veterans experiencing homelessness face substantial barriers to accessing health and social services. In 2016, the Veterans Affairs (VA) healthcare system launched a unique program to distribute video-enabled tablets to Veterans with access barriers.OBJECTIVE: Evaluate the use of VA-issued video telehealth tablets among Veterans experiencing homelessness in the VA system.DESIGN: Guided by the RE-AIM framework, we first evaluated the adoption of tablets among Veterans experiencing homelessness and housed Veterans. We then analyzed health record and tablet utilization data to compare characteristics of both subpopulations, and used multivariable logistic regression to identify factors associated with tablet use among Veterans experiencing homelessness.PATIENTS: In total, 12,148 VA patients receiving tablets between October 2017 and March 2019, focusing on the 1470 VA Veterans experiencing homelessness receiving tablets (12.1%).MAIN MEASURES: Tablet use within 6 months of receipt for mental health, primary or specialty care.KEY RESULTS: Nearly half (45.9%) of Veterans experiencing homelessness who received a tablet had a video visit within 6 months of receipt, most frequently for telemental health. Tablet use was more common among Veterans experiencing homelessness who were younger (AOR = 2.77; P <.001); middle-aged (AOR = 2.28; P <.001); in rural settings (AOR = 1.46; P =.005); and those with post-traumatic stress disorder (AOR = 1.64; P <.001), and less common among those who were Black (AOR = 0.43; P <.001) and those with a substance use disorder (AOR = 0.59; P <.001) or persistent housing instability (AOR = 0.75; P = .023).CONCLUSIONS: Telehealth care and connection for vulnerable populations are particularly salient during the COVID-19 pandemic but also beyond. VA's distribution of video telehealth tablets offers healthcare access to Veterans experiencing homelessness; however, barriers remain for subpopulations. Tailored training and support for these patients may be needed to optimize telehealth tablet use and effectiveness.

    View details for DOI 10.1007/s11606-021-06900-8

    View details for PubMedID 34027612

  • Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot. Journal of general internal medicine Wong, M. S., Luger, T. M., Katz, M. L., Stockdale, S. E., Ewigman, N. L., Jackson, J. L., Zulman, D. M., Asch, S. M., Ong, M. K., Chang, E. T. 2021


    BACKGROUND: Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value.OBJECTIVE: To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients.DESIGN: A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation.PARTICIPANTS: High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites.APPROACH: We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects.KEY RESULTS: Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization.CONCLUSIONS: Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).

    View details for DOI 10.1007/s11606-021-06869-4

    View details for PubMedID 33987789

  • Subgroups of High-Risk Veterans Affairs Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization. Medical care Blalock, D. V., Maciejewski, M. L., Zulman, D. M., Smith, V. A., Grubber, J., Rosland, A., Weidenbacher, H. J., Greene, L., Zullig, L. L., Whitson, H. E., Hastings, S. N., Hung, A. 2021; 59 (5): 410–17


    OBJECTIVE: Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death.STUDY DESIGN AND SETTING: SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression.RESULTS: Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14).CONCLUSION: Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.

    View details for DOI 10.1097/MLR.0000000000001526

    View details for PubMedID 33821830

  • Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic. Telemedicine journal and e-health : the official journal of the American Telemedicine Association Jacobs, J., Ferguson, J. M., Van Campen, J., Yefimova, M., Greene, L., Heyworth, L., Zulman, D. M. 2021


    Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.

    View details for DOI 10.1089/tmj.2020.0530

    View details for PubMedID 33887166

  • The association between alcohol use, all-cause, and cardiovascular disease-related hospitalizations or death in older, high-risk Veterans. Alcoholism, clinical and experimental research Blalock, D. V., Grubber, J., Smith, V. A., Zulman, D. M., Weidenbacher, H. J., Greene, L., Dedert, E. A., Maciejewski, M. L. 2021


    BACKGROUND: The prevalence of alcohol misuse among older adults has dramatically grown in the past decade, yet little is known about the association between alcohol misuse and hospitalization and death in this patient population.METHODS: We examined the association between alcohol use (measured by a screening instrument in primary care) and 6-month hospitalization or death (all-cause and cardiovascular disease (CVD)-related) via electronic health records (EHR) in a nationally representative sample of older, high-risk Veterans. Models were adjusted for sociodemographic and clinical characteristics, including frailty and comorbid conditions.RESULTS: The all-cause hospitalization or death rate at 6 months was 14.9%, and the CVD-related hospitalization or death rate was 1.8%. In adjusted analyses, all-cause hospitalization or death was higher in older Veterans that were non-drinkers or harmful use drinkers compared to moderate use drinkers, but CVD-related hospitalization or death was similar in all categories of drinking.CONCLUSIONS: These findings suggest that the complex association between alcohol and all-cause acute care utilization found in the broader population is similar in older, high-risk Veteran patients. These findings did not support any association between alcohol and CVD-specific hospitalizations.

    View details for DOI 10.1111/acer.14610

    View details for PubMedID 33844300

  • Psychometric evaluation of a patient-reported item bank for healthcare engagement. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Schalet, B. D., Reise, S. P., Zulman, D. M., Lewis, E. T., Kimerling, R. 2021


    PURPOSE: Healthcare engagement is a core measurement target for efforts to improve healthcare systems. This construct is broadly defined as the extent to which healthcare services represent collaborative partnerships with patients. Previous qualitative work operationalized healthcare engagement as generalized self-efficacy in four related subdomains: self-management, collaborative communication, health information use, and healthcare navigation. Building on this work, our objective was to establish a healthcare engagement instrument that is sufficiently unidimensional to yield a single score.METHOD: We conducted cognitive interviews followed by a nation-wide mail survey of US Veteran Administration (VA) healthcare users. Data were collected on 49 candidate healthcare engagement items, as well as measures of self-efficacy for managing symptoms, provider communication, and perceived access. Items were subjected to exploratory bifactor, statistical learning, and IRT analyses.RESULTS: Cognitive interviews were completed by 56 patients and 9552 VA healthcare users with chronic conditions completed the mail survey. Participants were mostly white and male but with sizable minority participation. Psychometric analyses and content considerations reduced the item pool to 23 items, which demonstrated a strong general factor (OmegaH of .89). IRT analyses revealed a high level of reliability across the trait range and little DIF across groups. Most health information use items were removed during analyses, suggesting a more independent role for this domain.CONCLUSION: We provide quantitative evidence for a relatively unidimensional measure of healthcare engagement. Despite developed with VA healthcare users, the measure is intended for general use. Future work includes short-form development and validation with other patient groups.

    View details for DOI 10.1007/s11136-021-02824-2

    View details for PubMedID 33835412

  • ADAPTING A DYADIC CHRONIC ILLNESS SELF-CARE PROGRAM FOR THE INTERNET: METHODOLOGY AND USABILITY Trivedi, R. B., Hirayama, S. K., Suresh, M., Risbud, R., Humber, M. B., Zulman, D. M., Asch, S. M., Nelson, K., Timko, C., Humphreys, K., Piette, J. OXFORD UNIV PRESS INC. 2021: S34
  • Evaluating the Effectiveness of Diabetes Shared Medical Appointments (SMAs) as Implemented in Five Veterans Affairs Health Systems: a Multi-site Cluster Randomized Pragmatic Trial. Journal of general internal medicine Heisler, M., Burgess, J., Cass, J., Chardos, J. F., Guirguis, A. B., Strohecker, L. A., Tremblay, A. S., Wu, W., Zulman, D. M. 2021


    OBJECTIVE: To examine whether diabetes shared medical appointments (SMAs) implemented as part of usual clinical practice in diverse health systems are more effective than usual care in improving and sustaining A1c improvements.RESEARCH DESIGN AND METHODS: A multi-site cluster randomized pragmatic trial examining implementation in clinical practice of diabetes SMAs in five Veterans Affairs (VA) health systems was conducted from 2016 to 2020 among 1537 adults with type 2 diabetes and elevated A1cs. Eligible patients were randomly assigned to either: (1) invitation to participate in a series of SMAs totaling 8-9h; or (2) continuation of usual care. Relative change in A1c (primary outcome) and in systolic blood pressure, insulin starts, statin starts, and anti-hypertensive medication classes (secondary outcomes) were measured as part of usual clinical care at baseline, at 6months and at 12months (~7months after conclusion of the final SMA in four of five sites). We examined outcomes in three samples of SMA participants: all those scheduled for a SMA, those attending at least one SMA, and those attending at least half of SMAs.RESULTS: Baseline mean A1c was 9.0%. Participants scheduled for an SMA achieved A1c reductions 0.35% points greater than the control group between baseline and 6-months follow up (p = .001). Those who attended at least one SMA achieved reductions 0.42 % points greater (p<.001), and those who attended at least half of scheduled SMAs achieved reductions 0.53 % points greater (p < .001) than the control group. At 12-month follow-up, the three SMA analysis samples achieved reductions from baseline ranging from 0.16 % points (p = 0.12) to 0.29 % points (p = .06) greater than the control group.CONCLUSIONS: Diabetes SMAs as implemented in real-life diverse clinical practices improve glycemic control more than usual care immediately after the SMAs, but relative gains are not maintained. Our findings suggest the need for further study of whether a longer term SMA model or other follow-up strategies would sustain relative clinical improvements associated with this intervention.TRIAL REGISTRATION: ID NCT02132676.

    View details for DOI 10.1007/s11606-020-06570-y

    View details for PubMedID 33532956

  • What Do Patient-Centered Medical Home (PCMH) Teams Need to Improve Care for Primary Care Patients with Complex Needs? Journal of general internal medicine Stockdale, S. E., Katz, M. L., Bergman, A. A., Zulman, D. M., Denietolis, A., Chang, E. T. 2021


    BACKGROUND: Intensive primary care (IPC) programs for patients with complex needs do not generate cost savings in most settings. Strengthening existing patient-centered medical homes (PCMH) to address the needs of these patients in primary care is a potential high-value alternative.OBJECTIVES: Explore PCMH team functioning and characteristics that may impact their ability to perform IPC tasks; identify the IPC components that could be incorporated into PCMH teams' workflow; and identify additional resources, trainings, and staff needed to better manage patients with complex needs in primary care.METHODS: We interviewed 44 primary care leaders, PCMH team members (providers, nurses, social workers), and IPC program leaders at 5 VA IPC sites and analyzed a priori themes using a matrix analysis approach.RESULTS: Higher-functioning PCMH teams were described as already performing most IPC tasks, including panel management and care coordination. All sites reported that PCMH teams had the knowledge and skills to perform IPC tasks, but not with the same intensity as specialized IPC teams. Home visits/assessments and co-attending appointments were perceived as not feasible to perform. Key stakeholders identified 6 categories of supports and capabilities that PCMH teams would need to better manage complex patients, with care coordination/management and fully staffed teams as the most frequently mentioned. Many thought that PCMH teams could make better use of existing VA and non-VA resources, but might need training in identifying and using those resources.CONCLUSIONS: PCMH teams can potentially offer certain clinic-based services associated with IPC programs, but tasks that are time intensive or require physical absence from clinic might require collaboration with community service providers and better use of internal and external healthcare system resources. Future studies should explore the feasibility of PCMH adoption of IPC tasks and the impact on patient outcomes.

    View details for DOI 10.1007/s11606-020-06563-x

    View details for PubMedID 33511564

  • Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) for Health Care Interventions: a Proposed Framework. Journal of general internal medicine Fischer, M. n., Safaeinili, N. n., Haverfield, M. C., Brown-Johnson, C. G., Zionts, D. n., Zulman, D. M. 2021


    Human-centered design (HCD), an empathy-driven approach to innovation that focuses on user needs, offers promise for the rapid design of health care interventions that are acceptable to patients, clinicians, and other stakeholders. Reviews of HCD in healthcare, however, note a need for greater rigor, suggesting an opportunity for integration of elements from traditional research and HCD. A strategy that combines HCD principles with evidence-grounded health services research (HSR) methods has the potential to strengthen the innovation process and outcomes. In this paper, we review the strengths and limitations of HCD and HSR methods for intervention design, and propose a novel Approach to Human-centered, Evidence-driven Adaptive Design (AHEAD) framework. AHEAD offers a practical guide for the design of creative, evidence-based, pragmatic solutions to modern healthcare challenges.

    View details for DOI 10.1007/s11606-020-06451-4

    View details for PubMedID 33537952

  • "Relationship between substance use disorder (SUD) and healthcare fragmentation patterns in veterans at high-risk for hospitalization" (SW19) Rossi, F., Timko, C., Javier, S. J., Zulman, D. M., Greene, L., Singer, S., Vanneman, M. E., Goldstein, M., Trivedi, R. BMC. 2020
  • Impact of VHA's primary care intensive management program on dual system use. Healthcare (Amsterdam, Netherlands) Wong, E. S., Guo, R., Yoon, J., Zulman, D. M., Asch, S. M., Ong, M. K., Chang, E. T. 2020; 8 (3): 100450

    View details for DOI 10.1016/j.hjdsi.2020.100450

    View details for PubMedID 32919588

  • "It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients CHRONIC ILLNESS Schwartz, R., Zulman, D., Gray, C., Goldstein, M. K., Trivedi, R. 2020; 16 (3): 201–11
  • OUTPATIENT CARE FRAGMENTATION PATTERNS AND ASSOCIATION WITH HOSPITALIZATION IN HIGH-RISK VA PATIENTS Zulman, D. M., Greene, A. L., Wagner, T. H., Maciejewski, M., Singer, S., Slightam, C., Trivedi, R., Vanneman, M., Asch, S., Yoon, J., Goldstein, M. K., Boothroyd, D. SPRINGER. 2020: S216
  • RESOURCED FOR RESPONSIVENESS: HOW RIMARY CARE INTENSIVE MANAGEMENT FOSTERED GOOD PAIN CARE Giannitrapani, K., Holliday, J., McCaa, M., Stockdale, S. E., Bergman, A., Katz, M. L., Rubenstein, L. V., Zulman, D. M., Chang, E. T. SPRINGER. 2020: S257–S258
  • Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans. JAMA network open Chang, E. T., Zulman, D. M., Nelson, K. M., Rosland, A., Ganz, D. A., Fihn, S. D., Piegari, R., Rubenstein, L. V. 2020; 3 (6): e208120


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

    View details for DOI 10.1001/jamanetworkopen.2020.8120

    View details for PubMedID 32597993

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


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

    View details for DOI 10.2196/15682

    View details for PubMedID 32293573

  • Advancing Evidence Synthesis from Effectiveness to Implementation: Integration of Implementation Measures into Evidence Reviews Tierney, A. A., Haverfield, M. C., McGovern, M. P., Zulman, D. M. SPRINGER. 2020: 1219–26


    In order to close the gap between discoveries that could improve health, and widespread impact on routine health care practice, there is a need for greater attention to the factors that influence dissemination and implementation of evidence-based practices. Evidence synthesis projects (e.g., systematic reviews) could contribute to this effort by collecting and synthesizing data relevant to dissemination and implementation. Such an advance would facilitate the spread of high-value, effective, and sustainable interventions.The objective of this paper is to evaluate the feasibility of extracting factors related to implementation during evidence synthesis in order to enhance the replicability of successes of studies of interventions in health care settings.Drawing on the implementation science literature, we suggest 10 established implementation measures that should be considered when conducting evidence synthesis projects. We describe opportunities to assess these constructs in current literature and illustrate these methods through an example of a systematic review.Twenty-nine studies of interventions aimed at improving clinician-patient communication in clinical settings.We identified acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, intervention complexity, penetration, reach, and sustainability as factors that are feasible and appropriate to extract during an evidence synthesis project.To fully understand the potential value of a health care innovation, it is important to consider not only its effectiveness, but also the process, demands, and resource requirements involved in downstream implementation. While there is variation in the degree to which intervention studies currently report implementation factors, there is a growing demand for this information. Abstracting information about these factors may enhance the value of systematic reviews and other evidence synthesis efforts, improving the dissemination and adoption of interventions that are effective, feasible, and sustainable across different contexts.

    View details for DOI 10.1007/s11606-019-05586-3

    View details for Web of Science ID 000544932500033

    View details for PubMedID 31848862

    View details for PubMedCentralID PMC7174479

  • Virtual Care Expansion in the Veterans Health Administration During the COVID-19 Pandemic: Clinical Services and Patient Characteristics Associated with Utilization. Journal of the American Medical Informatics Association : JAMIA Ferguson, J. M., Jacobs, J. n., Yefimova, M. n., Greene, L. n., Heyworth, L. n., Zulman, D. M. 2020


    To describe the shift from in-person to virtual care within Veterans Affairs (VA) during the early phase of the COVID-19 pandemic, and to identify at-risk patient populations who require greater resources to overcome access barriers to virtual care.Outpatient encounters (N = 42,916,349) were categorized by care type (e.g. primary, mental health, etc.) and delivery method (e.g., in-person, video). For 5,400,878 Veterans, we used Generalized Linear models to identify patient sociodemographic and clinical characteristics associated with: 1) use of virtual (phone or video) care versus no virtual care and 2) use of video care versus no video care; between 3/11/2020 and 6/6/2020.By June, 58% of VA care was provided virtually compared to only 14% prior. Patients with lower income, higher disability, and more chronic conditions were more likely to receive virtual care during the pandemic. Yet, Veterans aged 45-64 and 65+ were less likely to use video care compared to those aged 18-44 (aRR 0.80 [95%CI 0.79, 0.82] and 0.50 [0.48, 0.52], respectively). Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban (0.88 [0.86, 0.90]) and non-homeless Veterans (0.89 [0.86, 0.92]).Veterans with high clinical or social need had higher likelihood of virtual service use early in the COVID-19 pandemic, however, older, homeless, and rural Veterans were less likely to have video visits, raising concerns for access barriers.While virtual care may expand access, access barriers must be addressed to avoid exacerbating disparities.

    View details for DOI 10.1093/jamia/ocaa284

    View details for PubMedID 33125032

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

    View details for DOI 10.1001/jama.2019.19003

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


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

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

    View details for PubMedID 31919725

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


    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


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

    View details for DOI 10.1136/bmjopen-2019-030831

    View details for PubMedID 31685506

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


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

    View details for DOI 10.1097/MLR.0000000000001240

    View details for PubMedID 31688570

  • Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter JOURNAL OF GERIATRIC PSYCHIATRY AND NEUROLOGY Schwartz, R., Trivedi, R., Gray, C., Lorenz, K. A., Zulman, D. 2019; 32 (5): 246–56
  • Increasing Mental Health Care Access, Continuity, and Efficiency for Veterans Through Telehealth With Video Tablets. Psychiatric services (Washington, D.C.) Jacobs, J. C., Blonigen, D. M., Kimerling, R., Slightam, C., Gregory, A. J., Gurmessa, T., Zulman, D. M. 2019: appips201900104


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

    View details for DOI 10.1176/

    View details for PubMedID 31378193

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


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

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

    View details for PubMedID 31140094

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


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

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

    View details for PubMedID 31098977

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


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

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

    View details for PubMedID 31098966

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

    View details for PubMedID 31011959

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


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

    View details for PubMedID 31046525

  • Making connections: nationwide implementation of video telehealth tablets to address access barriers in veterans. JAMIA open Zulman, D. M., Wong, E. P., Slightam, C. n., Gregory, A. n., Jacobs, J. C., Kimerling, R. n., Blonigen, D. M., Peters, J. n., Heyworth, L. n. 2019; 2 (3): 323–29


    Video telehealth technology has the potential to enhance access for patients with clinical, social, and geographic barriers to care. We evaluated the implementation of a US Department of Veterans Affairs (VA) initiative to distribute tablets to high-need Veterans with access barriers.In this mixed methods implementation study, we examined tablet adoption (ie, facility-level tablet distribution rates and patient-level tablet utilization rates) and reach (ie, sociodemographic and clinical characteristics of tablet recipients) between 5/1/16 and 9/30/17. Concurrently, we surveyed 68 facility telehealth coordinators to determine the most common implementation barriers and facilitators, and then conducted interviews with telehealth coordinators and regional leadership to identify strategies that facilitated tablet distribution and use.86 VA facilities spanning all 18 geographic regions, distributed tablets to 6 745 patients. Recipients had an average age of 56 years, 53% lived in rural areas, 75% had a diagnosed mental illness, and they had a mean (SD) of 5 (3) chronic conditions. Approximately 4 in 5 tablet recipients used the tablet during the evaluation period. In multivariate logistic regression, tablet recipients were more likely to use their tablets if they were older and had fewer chronic conditions. Implementation barriers included insufficient training, staffing shortages, and provider disinterest (described as barriers by 59%, 55%, and 33% of respondents, respectively). Site readiness assessments, local champions, licensure modifications, and use of mandates and incentives were identified as strategies that may influence widespread implementation of home-based video telehealth.VA's initiative to distribute video telehealth tablets to high-need patients appears to have successfully reached individuals with social and clinical access barriers. Implementation strategies that address staffing constraints and provider engagement may enhance the impact of such efforts.

    View details for DOI 10.1093/jamiaopen/ooz024

    View details for PubMedID 32766533

    View details for PubMedCentralID PMC6952023

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


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

    View details for DOI 10.1089/tmj.2019.0179

    View details for PubMedID 31880502

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


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

    View details for PubMedID 31037542

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


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

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

    View details for PubMedID 31098965

  • 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


    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

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


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

    View details for PubMedID 29102480

  • Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., O'Brien, C. W., Slightam, C., Breland, J. Y., Krauth, D., Nevedal, A. L. 2018; 33 (11): 1937-1944
  • Persistence of High Health Care Costs among VA Patients HEALTH SERVICES RESEARCH Yoon, J., Chee, C., Su, P., Almenoff, P., Zulman, D. M., Wagner, T. H. 2018; 53 (5): 3898–3916


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

    View details for PubMedID 29862504

    View details for PubMedCentralID PMC6153161

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


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

    View details for PubMedID 30097977

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


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

    View details for PubMedID 29154464

    View details for PubMedCentralID PMC6052009

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


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

    View details for PubMedID 29868706

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


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

    View details for PubMedID 29698772

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


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

    View details for PubMedID 29800395

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


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

    View details for PubMedID 29800397

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


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

    View details for PubMedID 29358159

  • Intensive Outpatient Program Effects on High-need Patients' Access, Continuity, Coordination, and Engagement MEDICAL CARE Wu, F. M., Slightam, C. A., Wong, A. C., Asch, S. M., Zulman, D. M. 2018; 56 (1): 19–24
  • "It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients. Chronic illness Schwartz, R. n., Zulman, D. n., Gray, C. n., Goldstein, M. K., Trivedi, R. n. 2018: 1742395318799852


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

    View details for PubMedID 30208725

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


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

    View details for PubMedID 29135775

    View details for PubMedCentralID PMC4942413

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


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

    View details for DOI 10.1097/MLR.0000000000000833

    View details for PubMedID 29087980

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


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

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

    View details for PubMedID 28549471

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


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

    View details for DOI 10.1016/j.amepre.2016.10.006

    View details for PubMedID 27866825

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


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

    View details for DOI 10.1177/1742395317699448

    View details for PubMedID 28449592

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


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

    View details for DOI 10.1001/jamainternmed.2016.5974

    View details for PubMedID 27695822

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


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

    View details for DOI 10.2196/jmir.5594

    View details for Web of Science ID 000387985700014

    View details for PubMedID 27784650

    View details for PubMedCentralID PMC5103157

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


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

    View details for DOI 10.2196/mhealth.6445

    View details for Web of Science ID 000391888600003

    View details for PubMedID 27993761

    View details for PubMedCentralID PMC5206484

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


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

    View details for DOI 10.1111/jgs.14248

    View details for PubMedID 27385077

  • Opportunities to Enhance Value-Related Research in the US Department of Veterans Affairs JOURNAL OF GENERAL INTERNAL MEDICINE Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83
  • Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness. Healthcare (Amsterdam, Netherlands) Vaks, Y., Bensen, R., Steidtmann, D., Wang, T. D., Platchek, T. S., Zulman, D. M., Malcolm, E., Milstein, A. 2016; 4 (1): 57-68


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

    View details for DOI 10.1016/j.hjdsi.2015.09.001

    View details for PubMedID 27001100

    View details for PubMedCentralID PMC4805882

  • Transforming Care for Complex Patients: Addressing Interconnected Medical, Social, and Behavioral Challenges. Journal of general internal medicine Zulman, D. M., Grant, R. W. 2016; 31 (3): 263-4

    View details for DOI 10.1007/s11606-015-3554-5

    View details for PubMedID 26631098

    View details for PubMedCentralID PMC4762822

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


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

    View details for DOI 10.1016/j.hjdsi.2015.12.005

    View details for PubMedID 27001095

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


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

    View details for PubMedID 26765149

    View details for PubMedCentralID PMC4942413

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


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

    View details for DOI 10.1176/

    View details for PubMedID 25930040

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


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

    View details for DOI 10.2196/jmir.3801

    View details for Web of Science ID 000356819800012

    View details for PubMedID 26104000

    View details for PubMedCentralID PMC4526957

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


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

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

    View details for PubMedID 26863335

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


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

    View details for DOI 10.1097/MLR.0000000000000284

    View details for PubMedID 25767965

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


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

    View details for PubMedID 26306285

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


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

    View details for PubMedID 26958279

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


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

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

    View details for Web of Science ID 000345410200010

    View details for PubMedCentralID PMC4239286

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

    View details for DOI 10.1161/STROKEAHA.114.006236

    View details for Web of Science ID 000342794700056

    View details for PubMedID 25123221

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

    View details for DOI 10.1161/STROKEAHA.114.006236

    View details for PubMedID 25123221

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


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

    View details for DOI 10.1136/amiajnl-2014-002723

    View details for PubMedID 24740865

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


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

    View details for DOI 10.1097/MLR.0000000000000061

    View details for PubMedID 24561756

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


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

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

    View details for PubMedID 24294324

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


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

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

    View details for Web of Science ID 000209413000005

    View details for PubMedCentralID PMC3830019

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


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

    View details for DOI 10.1089/jpm.2013.9491

    View details for Web of Science ID 000322114600012

    View details for PubMedID 23777331

    View details for PubMedCentralID PMC3717194

  • MULTIMORBIDITY AND HEALTH CARE UTILIZATION AMONG HIGH-COST PATIENTS: IMPLICATIONS FOR CARE COORDINATION 36th Annual Meeting of the Society-of-General-Internal-Medicine Zulman, D., Yoon, J., Cohen, D. M., Wagner, T. H., Ritchie, C., Asch, S. SPRINGER. 2013: S123–S124
  • Facilitating out-of-home caregiving through health information technology: survey of informal caregivers' current practices, interests, and perceived barriers. Journal of medical Internet research Zulman, D. M., Piette, J. D., Jenchura, E. C., Asch, S. M., Rosland, A. 2013; 15 (7)


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

    View details for DOI 10.2196/jmir.2472

    View details for PubMedID 23841987

    View details for PubMedCentralID PMC3713893

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


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

    View details for Web of Science ID 000309036300002

    View details for PubMedID 22928756

  • A NOVEL CONCEPTUAL MODEL FOR CLINICAL DECISION COMPLEXITY Zulman, D. M., Martins, S. B., Asch, S., Goldstein, M. K. SPRINGER. 2012: S106–S107
  • Access to the Medical Record ANNALS OF INTERNAL MEDICINE Zulman, D. M., Nazi, K. M., Asch, S. M., Wagner, T. H. 2012; 156 (9): 668-668
  • The influence of diabetes psychosocial attributes and self-management practices on change in diabetes status PATIENT EDUCATION AND COUNSELING Zulman, D. M., Rosland, A., Choi, H., Langa, K. M., Heisler, M. 2012; 87 (1): 74-80


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

    View details for DOI 10.1016/j.pec.2011.07.013

    View details for Web of Science ID 000303182000013

    View details for PubMedID 21840149

    View details for PubMedCentralID PMC3229832

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


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

    View details for DOI 10.1089/tmj.2011.0109

    View details for Web of Science ID 000301041200006

    View details for PubMedID 22304439

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


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

    View details for DOI 10.1002/pon.1900

    View details for Web of Science ID 000300987400014

    View details for PubMedID 21830255

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


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

    View details for DOI 10.2196/jmir.1552

    View details for Web of Science ID 000287447100016

    View details for PubMedID 21324832

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


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

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

    View details for Web of Science ID 000276721900010

    View details for PubMedID 20127197

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


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

    View details for Web of Science ID 000273953000001

    View details for PubMedID 20083825

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


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

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

    View details for Web of Science ID 000261104300003

    View details for PubMedID 19120980

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


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

    View details for Web of Science ID 000252211100004

    View details for PubMedID 17982203

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


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

    View details for Web of Science ID 000189164000012

    View details for PubMedID 14978326

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