Nirav R. Shah, MD, MPH

All Publications

• Testing and Evaluation of Health Care Applications of Large Language Models: A Systematic Review. JAMA Bedi, S., Liu, Y., Orr-Ewing, L., Dash, D., Koyejo, S., Callahan, A., Fries, J. A., Wornow, M., Swaminathan, A., Lehmann, L. S., Hong, H. J., Kashyap, M., Chaurasia, A. R., Shah, N. R., Singh, K., Tazbaz, T., Milstein, A., Pfeffer, M. A., Shah, N. H. 2024

  Abstract

  Large language models (LLMs) can assist in various health care activities, but current evaluation approaches may not adequately identify the most useful application areas.To summarize existing evaluations of LLMs in health care in terms of 5 components: (1) evaluation data type, (2) health care task, (3) natural language processing (NLP) and natural language understanding (NLU) tasks, (4) dimension of evaluation, and (5) medical specialty.A systematic search of PubMed and Web of Science was performed for studies published between January 1, 2022, and February 19, 2024.Studies evaluating 1 or more LLMs in health care.Three independent reviewers categorized studies via keyword searches based on the data used, the health care tasks, the NLP and NLU tasks, the dimensions of evaluation, and the medical specialty.Of 519 studies reviewed, published between January 1, 2022, and February 19, 2024, only 5% used real patient care data for LLM evaluation. The most common health care tasks were assessing medical knowledge such as answering medical licensing examination questions (44.5%) and making diagnoses (19.5%). Administrative tasks such as assigning billing codes (0.2%) and writing prescriptions (0.2%) were less studied. For NLP and NLU tasks, most studies focused on question answering (84.2%), while tasks such as summarization (8.9%) and conversational dialogue (3.3%) were infrequent. Almost all studies (95.4%) used accuracy as the primary dimension of evaluation; fairness, bias, and toxicity (15.8%), deployment considerations (4.6%), and calibration and uncertainty (1.2%) were infrequently measured. Finally, in terms of medical specialty area, most studies were in generic health care applications (25.6%), internal medicine (16.4%), surgery (11.4%), and ophthalmology (6.9%), with nuclear medicine (0.6%), physical medicine (0.4%), and medical genetics (0.2%) being the least represented.Existing evaluations of LLMs mostly focus on accuracy of question answering for medical examinations, without consideration of real patient care data. Dimensions such as fairness, bias, and toxicity and deployment considerations received limited attention. Future evaluations should adopt standardized applications and metrics, use clinical data, and broaden focus to include a wider range of tasks and specialties.

  View details for DOI 10.1001/jama.2024.21700

  View details for PubMedID 39405325

  View details for PubMedCentralID PMC11480901

• We Need to Rethink Nursing Homes. Journal of general internal medicine Farber, J. I., Shah, N. R. 2024

  View details for DOI 10.1007/s11606-024-08830-7

  View details for PubMedID 38831251

• Building a National Public Health System in the United States. The New England journal of medicine Hamburg, M. A., Cohen, M., DeSalvo, K., Gerberding, J., Khaldun, J., Lakey, D., MacKenzie, E., Palacio, H., Shah, N. R. 2022

  View details for DOI 10.1056/NEJMp2207374

  View details for PubMedID 35726801

• Diagnostic Excellence and Patient Safety: Strategies and Opportunities. JAMA Shah, N. R., Gandhi, T. K., Bates, D. W. 2022

  View details for DOI 10.1001/jama.2022.9629

  View details for PubMedID 35687350

• What AI in Health Care Can Learn from the Long Road to Autonomous Vehicles New England Journal of Medicine Catalyst Norden, J. G., Shah, N. R. 2022; March
• Empowering clinical research in a decentralized world. NPJ digital medicine De Brouwer, W., Patel, C. J., Manrai, A. K., Rodriguez-Chavez, I. R., Shah, N. R. 2021; 4 (1): 102

  View details for DOI 10.1038/s41746-021-00473-w

  View details for PubMedID 34211085

• An Impact-Oriented Approach to Epidemiological Modeling. Journal of general internal medicine Shah, N. R., Lai, D. n., Wang, C. J. 2020

  View details for DOI 10.1007/s11606-020-06230-1

  View details for PubMedID 32959348

• Health Care in 2030: Will Artificial Intelligence Replace Physicians? Annals of internal medicine Shah, N. R. 2019

  View details for PubMedID 30802901

• Build vs. Buy: What Should Health Systems Do? Shah, N. R., Farkas, C. M., Kocher, B. New England Journal of Medicine. 2019 ; Care Redesign

  Abstract

  Full stack solutions are coming to health care

  NEJM Catalyst
• Predictive Analytics to Determine Next Year’s Highest-Cost Patients Shah, N. R., et al New England Journal of Medicine. 2017 ; NEJM Catalyst
• Healthcare's missing quality measure: time Shah, N. R., et al Harvard Business Review. 2017 ; Harvard Business Review
• Health Care That Targets Unmet Social Needs Shah, N. R., et al New England Jounal of Medicine. 2016 ; NEJM Catalyst
• Parenthood and Paychecks-The Gender Pay Gap in Medicine. JAMA Kim, K. M., Narayan, A., Shah, N. R., Milstein, A. 2024

  View details for DOI 10.1001/jama.2024.22123

  View details for PubMedID 39470655

• Beyond Brick and Mortar: The Rise of Street Medicine. Journal of general internal medicine Narayan, A., Shah, N., Hochman, M. 2024

  Abstract

  In 2023, approximately 650,000 people experienced homelessness (PEH) nightly in the United States, the highest number recorded in the country's history. This alarming statistic has made homelessness a key issue in the 2024 elections, especially with the White House's goal to reduce homelessness by 25% by 2025. Despite efforts and investments, homelessness remains a persistent public health challenge. The recent inclusion of street medicine services in Center for Medicare and Medicaid Services (CMS) billing codes represents a significant step forward. Street medicine, defined by CMS as healthcare provided in non-permanent locations to unsheltered individuals, now qualifies for Medicare reimbursement. This policy change, alongside state-level initiatives, aims to improve healthcare access for the unhoused, particularly older adults. However, challenges remain in establishing adequate fee schedules and integrating care management. Despite these obstacles, the integration of healthcare and housing services is crucial for addressing homelessness effectively, promoting stability, and improving health outcomes for PEH. This manuscript explores the history, practical guidance, and potential impacts of these developments on homelessness and public health.

  View details for DOI 10.1007/s11606-024-08880-x

  View details for PubMedID 38937362

  View details for PubMedCentralID 4520328

• Decentralizing Health Care: History and Opportunities of Web3. JMIR formative research Narayan, A., Weng, K., Shah, N. 2024; 8: e52740

  Abstract

  This paper explores the relationship between the development of the internet and health care, highlighting their parallel growth and mutual influence. It delves into the transition from the early, static days of Web 1.0, akin to siloed physician expertise in health care, to the more interactive and patient-centric era of Web 2.0, which was accompanied by advancements in medical technologies and patient engagement. This paper then focuses on the emerging era of Web3-the decentralized web-which promises a transformative shift in health care, particularly in how patient data are managed, accessed, and used. This shift toward Web3 involves using blockchain technology for decentralized data storage to enhance patient data access, control, privacy, and value. This paper also examines current applications and pilot projects demonstrating Web3's practical use in health care and discusses key questions and considerations for its successful implementation.

  View details for DOI 10.2196/52740

  View details for PubMedID 38536235

• Association between maternal employment status and presence of children with major congenital anomalies in Denmark. BMC public health Kim, K. M., Farkas, D. K., Wong, V., Hjorth, C. F., Horváth-Puhó, E., Cahan, E., Cohen, E., Shah, N. R., Sørensen, H. T., Milstein, A. 2024; 24 (1): 715

  Abstract

  The burden of caring for children with complex medical problems such as major congenital anomalies falls principally on mothers, who in turn suffer a variety of potentially severe economic consequences. As well, health consequences of caregiving often further impact the social and economic prospects of mothers of children with major congenital anomalies (MCMCAs). Evaluating the long-term economic consequences of extensive in-home caregiving among MCMCAs can inform strategies to mitigate these effects.To assess whether MCMCAs face reduced employment and increased need for disability benefits over a 20-year period.A population-based matched cohort study.Denmark.All women who gave birth to a singleton child with a major congenital anomaly in Denmark between January 1, 1997 and December 31, 2017 (n = 23,637) and a comparison cohort of mothers matched by maternal age, parity, and infant's year of birth (n = 234,586).Liveborn infant with a major congenital anomaly.The primary outcome was mothers' employment status, stratified by their child's age. Employment status was categorized as employed, outside the workforce (on temporary leave, holding a flexible job, or pursuing education), or unemployed; the number of weeks in each category was measured over time. The secondary outcome was time to receipt of a disability pension, which in Denmark implies permanent exit from the labor market. We used a negative binomial regression model to estimate the number of weeks in each employment category, stratified by the child's age (i.e., 0-1 year, > 1-6 years, 7-13 years, 14-18 years). A Cox proportional hazards regression model was used to compute hazard ratios as a measure of the relative risk of receiving a disability pension. Rate ratios and hazard ratios were adjusted for maternal demographics, pregnancy history, health, and infant's year of birth.During 1-6 years after delivery, MCMCAs were outside the workforce for a median of 50 weeks (IQR, 6-107 weeks), while members of the comparison cohort were outside the workforce for a median of 48 weeks (IQR, 4-98 weeks), corresponding to an adjusted rate ratio [ARR] of 1.05 (95% confidence interval [CI], 1.04-1.07). During the first year after delivery, MCMCAs were more likely to be employed than mothers in the comparison cohort (ARR, 1.08; 95% CI, 1.06-1.10). At all timepoints thereafter, MCMCAs had a lower rate of workforce participation. The rate of being outside the workforce was 5% higher than mothers in the comparison cohort during 1-6 years after delivery (ARR, 1.05; 95% CI, 1.04-1.07), 9% higher during 7-13 years after delivery (ARR, 1.09; 95% CI, 1.06-1.12), and 12% higher during 14-18 years after delivery (ARR, 1.12; 95% CI, 1.07-1.18). Overall, MCMCAs had a 20% increased risk of receiving a disability pension during follow-up than mothers in the matched comparison cohort [incidence rates 3.10 per 1000 person-years (95% CI, 2.89-3.32) vs. 2.34 per 1000 person-years (95% CI, 2.29-2.40), adjusted hazard ratio, 1.20; 95% CI, 1.11-1.29].MCMCAs were less likely to participate in the Danish workforce, less likely to be employed, and more likely to receive disability pensions than mothers of unaffected children. The rate of leaving the workforce intensified as their affected children grew older. The high demands of caregiving among MCMCAs may have long-term employment consequences even in nations with comprehensive and heavily tax-supported childcare systems, such as Denmark.

  View details for DOI 10.1186/s12889-024-18190-w

  View details for PubMedID 38443822

  View details for PubMedCentralID 7203968

• Integrating Public and Population Health Into Medical Education Curricula: Opportunities and Challenges for Reform. Academic medicine : journal of the Association of American Medical Colleges Mehta, S. H., Shah, N. R. 2023

  Abstract

  ABSTRACT: In a review of U.S. medical education curricular guidance, from premedical studies through to continuing medical education, Maeshiro and colleagues found limited examples of public and population health topics. In this Commentary, the authors emphasize the importance of including public and population health in the curriculum, pointing to curricular reform efforts to integrate these topics into teaching of basic sciences and clinical studies. In addition, they consider the expectations placed on physicians to meet the needs of the population and argue that policies that support public health funding, infrastructure, and workers are also critical to improving the health of communities.

  View details for DOI 10.1097/ACM.0000000000005469

  View details for PubMedID 37801585

• Continuous monitoring of eating and sleeping behaviors in the home environments of older adults: a case study demonstration. Frontiers in public health Narayan, A., Goncharova, M., Goncharov, M., Gostine, A., Shah, N. R., Kaplan, R. M. 2023; 11: 1277714

  Abstract

  Accurate observation of patient functioning is necessary for rigorous clinical research and for improving the quality of patient care. However, clinic or laboratory environments systematically differ from the contexts of everyday life. Further, assessments that are completed in a single institutional session may not be generalizable. Here, we describe a computer vision methodology that measures human functioning continuously in the environments where patients live, sleep, and eat.

  View details for DOI 10.3389/fpubh.2023.1277714

  View details for PubMedID 38283288

  View details for PubMedCentralID PMC10811267

• Development and Assessment of an Artificial Intelligence-Based Tool for Ptosis Measurement in Adult Myasthenia Gravis Patients Using Selfie Video Clips Recorded on Smartphones. Digital biomarkers Lootus, M., Beatson, L., Atwood, L., Bourdais, T., Steyaert, S., Sarabu, C., Framroze, Z., Dickinson, H., Steels, J., Lewis, E., Shah, N. R., Rinaldo, F. 2023; 7 (1): 63-73

  Abstract

  Introduction: Myasthenia gravis (MG) is a rare autoimmune disease characterized by muscle weakness and fatigue. Ptosis (eyelid drooping) occurs due to fatigue of the muscles for eyelid elevation and is one symptom widely used by patients and healthcare providers to track progression of the disease. Margin reflex distance 1 (MRD1) is an accepted clinical measure of ptosis and is typically assessed using a hand-held ruler. In this work, we develop an AI model that enables automated measurement of MRD1 in self-recorded video clips collected using patient smartphones.Methods: A 3-month prospective observational study collected a dataset of video clips from patients with MG. Study participants were asked to perform an eyelid fatigability exercise to elicit ptosis while filming "selfie" videos on their smartphones. These images were collected in nonclinical settings, with no in-person training. The dataset was annotated by non-clinicians for (1) eye landmarks to establish ground truth MRD1 and (2) the quality of the video frames. The ground truth MRD1 (in millimeters, mm) was calculated from eye landmark annotations in the video frames using a standard conversion factor, the horizontal visible iris diameter of the human eye. To develop the model, we trained a neural network for eye landmark detection consisting of a ResNet50 backbone plus two dense layers of 78 dimensions on publicly available datasets. Only the ResNet50 backbone was used, discarding the last two layers. The embeddings from the ResNet50 were used as features for a support vector regressor (SVR) using a linear kernel, for regression to MRD1, in mm. The SVR was trained on data collected remotely from MG patients in the prospective study, split into training and development folds. The model's performance for MRD1 estimation was evaluated on a separate test fold from the study dataset.Results: On the full test fold (N = 664 images), the correlation between the ground truth and predicted MRD1 values was strong (r = 0.732). The mean absolute error was 0.822 mm; the mean of differences was -0.256 mm; and 95% limits of agreement (LOA) were -0.214-1.768 mm. Model performance showed no improvement when test data were gated to exclude "poor" quality images.Conclusions: On data generated under highly challenging real-world conditions from a variety of different smartphone devices, the model predicts MRD1 with a strong correlation (r = 0.732) between ground truth and predicted MRD1.

  View details for DOI 10.1159/000531224

  View details for PubMedID 37545566

• A Brief History of Exposure Notification During the COVID-19 Pandemic in the United States, 2020-2021. Public health reports (Washington, D.C. : 1974) Bair, H., Wanger, J. D., Shah, N. R. 2022: 333549221099533

  Abstract

  The swift global spread of COVID-19 prompted public health authorities to explore digital technologies to aid in contact tracing for infection control. Exposure notification, a mobile device-based technology that notifies individuals of potential exposure to COVID-19 without requiring personally identifiable information, has been broadly favored because of its relative ease of use, scalability, and protection of personal privacy. Although several exposure notification protocols were developed, a partnership between Google and Apple led to the development of the most widely implemented exposure notification protocol in the world, including in the United States. In this article, we first describe the development of the Google Apple Exposure Notification (GAEN) protocol, noting the value of the discourse among software developers and public health authorities concerning the protocol's design and features. We track states' deployment of GAEN mobile applications (apps) and population-level adoption rates, finding the nationwide rollout of GAEN apps to be more fragmented than anticipated. We then discuss how the limited data collected from these apps make assessments of their effectiveness challenging. Finally, we consider the importance of the federal government playing a greater role in GAEN's early development, emphasize the power of public-private partnerships, and highlight the overriding importance of public messaging over technological details.

  View details for DOI 10.1177/00333549221099533

  View details for PubMedID 35674242

• Personalized digital intervention for depression based on social rhythm principles adds significantly to outpatient treatment. Frontiers in digital health Frank, E., Wallace, M. L., Matthews, M. L., Kendrick, J., Leach, J., Moore, T., Aranovich, G., Choudhury, T., Shah, N. R., Framroze, Z., Posey, G., Burgess, S., Kupfer, D. J. 2022; 4: 870522

  Abstract

  We conducted a 16-week randomized controlled trial in psychiatric outpatients with a lifetime diagnosis of a mood and/or anxiety disorder to measure the impact of a first-of-its-kind precision digital intervention software solution based on social rhythm regulation principles. The full intent-to-treat (ITT) sample consisted of 133 individuals, aged 18-65. An exploratory sub-sample of interest was those individuals who presented with moderately severe to severe depression at study entry (baseline PHQ-8 score ≥15; N=28). Cue is a novel digital intervention platform that capitalizes on the smartphone's ability to continuously monitor depression-relevant behavior patterns and use each patient's behavioral data to provide timely, personalized "micro-interventions," making this the first example of a precision digital intervention of which we are aware. Participants were randomly allocated to receive Cue plus care-as-usual or digital monitoring only plus care as usual. Within the full study and depressed-at-entry samples, we fit a mixed effects model to test for group differences in the slope of depressive symptoms over 16 weeks. To account for the non-linear trajectory with more flexibility, we also fit a mixed effects model considering week as a categorical variable and used the resulting estimates to test the group difference in PHQ change from baseline to 16 weeks. In the full sample, the group difference in the slope of PHQ-8 was negligible (Cohen's d=-0.10); however, the Cue group demonstrated significantly greater improvement from baseline to 16 weeks (p=0.040). In the depressed-at-entry sample, we found evidence for benefit of Cue. The group difference in the slope of PHQ-8 (Cohen's d=-0.72) indicated a meaningfully more rapid rate of improvement in the intervention group than in the control group. The Cue group also demonstrated significantly greater improvement in PHQ-8 from baseline to 16 weeks (p=0.009). We are encouraged by the size of the intervention effect in those who were acutely ill at baseline, and by the finding that across all participants, 80% of whom were receiving pharmacotherapy, we observed significant benefit of Cue at 16 weeks of treatment. These findings suggest that a social rhythm-focused digital intervention platform may represent a useful and accessible adjunct to antidepressant treatment (https://clinicaltrials.gov/ct2/show/NCT03152864?term=ellen+frank&draw=2&rank=3).

  View details for DOI 10.3389/fdgth.2022.870522

  View details for PubMedID 36120713

• Scaling Supply to Meet Behavioral Health Demand in New York State Nursing Homes New England Journal of Medicine Catalyst Simning, A., ..., Shah, N. 2022; 3 (10)

  View details for DOI 10.1056/CAT.22.0196

• Predicting Environmental Allergies from Real World Data Through a Mobile Study Platform. Journal of asthma and allergy Sarabu, C., Steyaert, S., Shah, N. R. 2021; 14: 259–64

  View details for DOI 10.2147/JAA.S292336

  View details for PubMedID 33776455

• Mothers of children with major congenital anomalies have increased health care utilization over a 20-year post-birth time horizon. PloS one Shah, N. R., Kim, K. M., Wong, V., Cohen, E., Rosenbaum, S., Cahan, E. M., Milstein, A., Sorensen, H. T., Horvath-Puho, E. 2021; 16 (12): e0260962

  Abstract

  OBJECTIVE: This population-based, matched cohort study aimed to evaluate utilization of health care services by mothers of children with major congenital anomalies (MCAs), compared to mothers of children without MCAs over a 20-year post-birth time horizon in Denmark.METHODS: Our analytic sample included mothers who gave birth to an infant with a MCA (n = 23,927) and a cohort of mothers matched to them by maternal age, parity and infant's year of birth (n = 239,076). Primary outcomes were period prevalence and mothers' quantity of health care utilization (primary, inpatient, outpatient, surgical, and psychiatric services) stratified by their child's age (i.e., ages 0-6 = before school, ages 7-13 = pre-school + primary education, and ages 14-18 = secondary education or higher). The secondary outcome measure was length of hospital stays. Outcome measures were adjusted for maternal age at delivery, parity, marital status, income quartile, level of education in the year prior to the index birth, previous spontaneous abortions, maternal pregnancy complications, maternal diabetes, hypertension, alcohol-related diseases, and maternal smoking.RESULTS: In both cohorts the majority of mothers were between 26 and 35 years of age, married, and employed, and 47% were primiparous. Mothers of infants with anomalies had greater utilization of outpatient, inpatient, surgical, and psychiatric services, compared with mothers in the matched cohort. Inpatient service utilization was greater in the exposed cohort up to 13 years after a child's birth, with the highest risk in the first six years after birth [adjusted risk ratio, 1.13; 95% confidence interval (CI), 1.12-1.14], with a decrease over time. Regarding the quantity of health care utilization, the greatest difference between the two groups was in inpatient service utilization, with a 39% increased rate in the exposed cohort during the first six years after birth (adjusted rate ratio, 1.39; 95% CI, 1.37-1.42). During the first 6 years after birth, mothers of children with anomalies stayed a median of 6 days (interquartile range [IQR], 3-13) in hospital overall, while the comparison cohort stayed a median of 4 days (IQR, 2-7) in hospital overall. Rates of utilization of outpatient clinics (adjusted rate ratio, 1.36; 95% CI, 1.29-1.42), as well as inpatient (adjusted rate ratio, 1.77; 95% CI, 1.68-1.87), and surgical services (adjusted rate ratio, 1.33; 95% CI, 1.26-1.41) was higher in mothers of children with multiple-organ MCAs during 0 to 6 years after birth. Among mothers at the lowest income levels, utilization of psychiatric clinic services increased to 59% and when their child was 7 to 13 years of age (adjusted rate ratio, 1.59; 95% CI, 1.24-2.03).CONCLUSION: Mothers of infants with a major congenital anomaly had greater health care utilization across services. Health care utilization decreased over time or remained stable for outpatient, inpatient, and surgical care services, whereas psychiatric utilization increased for up to 13 years after an affected child's birth. Healthcare utilization was significantly elevated among mothers of children with multiple MCAs and among those at the lowest income levels.

  View details for DOI 10.1371/journal.pone.0260962

  View details for PubMedID 34879106

• Achieving a Quintuple Aim for Telehealth in Pediatrics. Pediatric clinics of North America Cahan, E. M., Mittal, V., Shah, N. R., Thadaney-Israni, S. 2020; 67 (4): 683–705

  Abstract

  Pediatric practice increasingly involves providing care for children with medical complexity. Telehealth offers a strategy for providers and health care systems to improve care for these patients and their families. However, lack of awareness related to the unintended negative consequences of telehealth on vulnerable populations--coupled with failure to intentional design best practices for telehealth initiatives--implies that these novel technologies may worsen health disparities in the long run. This article reviews the positive and negative implications of telehealth. In addition, to achieve optimal implementation of telehealth, it discusses 10 considerations to promote optimal care of children using these technologies.

  View details for DOI 10.1016/j.pcl.2020.04.015

  View details for PubMedID 32650867

• Impact of Social Needs Navigation on Utilization Among High Utilizers in a Large Integrated Health System: a Quasi-experimental Study. Journal of general internal medicine Schickedanz, A., Sharp, A., Hu, Y. R., Shah, N. R., Adams, J. L., Francis, D., Rogers, A. 2019

  Abstract

  BACKGROUND: Programs addressing social determinants of health for high-utilizing patients are gaining interest among health systems as an avenue to promote health and decrease utilization.OBJECTIVE: To evaluate impacts of a social needs screening and navigation program for adult predicted high utilizers on total medical visit utilization.DESIGN: A prospective, quasi-experimental study using an intent-to-treat propensity-weighted difference-in-differences approach. Stratified analyses assessed intervention effects among three low-socioeconomic status sub-samples: patients in low-income areas, in low-education areas, and with Medicaid insurance.PARTICIPANTS: Predicted high utilizers-patients predicted to be in the highest 1% for total utilization in a large integrated health system.INTERVENTION: A telephonic social needs screening and navigation program.MAIN MEASURES: Primary difference-in-difference analyses compared total visit count utilization, including outpatient, emergency department (ED), and inpatient utilization, between the intervention and control groups at both in-network and out-of-network facilities. Prevalence of social needs among sample patients and their connection rates to social needs resources are also described.KEY RESULTS: The study included 34,225 patients (7107 intervention, 27,118 control). Most (53%) patients screened reported social needs, but only a minority (10%) of those with a need were able to connect with resources to address these needs. Primary analysis found total utilization visits decreased 2.2% (95% CI -4.5%, 0.1%; p=0.058) in the intervention group. Stratified analyses showed decreases in total utilization for all low-socioeconomic status subgroups receiving the intervention compared with controls: -7.0% (95% CI -11.9%, -1.9%; p=0.008) in the low-income area group, -11.5% (-17.6%, 5.0%; p<0.001) in the low-education area group, and -12.1% (-18.1%, -5.6%; p<0.001) in the Medicaid group.CONCLUSIONS: Social needs navigation programs for high-utilizing patients may have modest effects on utilization for the population overall. However, significant decreases in utilization were found among low-socioeconomic status patients more likely to experience social needs.

  View details for DOI 10.1007/s11606-019-05123-2

  View details for PubMedID 31228054

• Segmentation of High-Cost Adults in an Integrated Healthcare System Based on Empirical Clustering of Acute and Chronic Conditions JOURNAL OF GENERAL INTERNAL MEDICINE Davis, A. C., Shen, E., Shah, N. R., Glenn, B. A., Ponce, N., Telesca, D., Gould, M. K., Needleman, J. 2018; 33 (12): 2171–79

  Abstract

  High-cost patients are a frequent focus of improvement projects based on primary care and other settings. Efforts to characterize high-cost, high-need patients are needed to inform care planning, but such efforts often rely on a priori assumptions, masking underlying complexities of a heterogenous population.To define recognizable subgroups of patients among high-cost adults based on clinical conditions, and describe their survival and future spending.Retrospective observational cohort study.Within a large integrated delivery system with 2.7 million adult members, we selected the top 1% of continuously enrolled adults with respect to total healthcare expenditures during 2010.We used latent class analysis to identify clusters of alike patients based on 53 hierarchical condition categories. Prognosis as measured by healthcare spending and survival was assessed through 2014 for the resulting classes of patients.Among 21,183 high-cost adults, seven clinically distinctive subgroups of patients emerged. Classes included end-stage renal disease (12% of high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over 4 years of follow-up, 6566 (31%) patients died, and survival in the classes ranged from 43 to 88%. Spending regressed to the mean in all classes except the ESRD and diabetes with multiple comorbidities groups.Data-driven characterization of high-cost adults yielded clinically intuitive classes that were associated with survival and reflected markedly different healthcare needs. Relatively few high-cost patients remain persistently high cost over 4 years. Our results suggest that high-cost patients, while not a monolithic group, can be segmented into few subgroups. These subgroups may be the focus of future work to understand appropriateness of care and design interventions accordingly.

  View details for PubMedID 30182326

  View details for PubMedCentralID PMC6258619

• Putting the Health of Communities and Populations First JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Goldman, L. R., Kumanyika, S. K., Shah, N. R. 2016; 316 (16): 1649-1650

  View details for DOI 10.1001/jama.2016.14800

  View details for Web of Science ID 000386107800017

  View details for PubMedID 27668815

• Redesigning the Regulatory Framework for Ambulatory Care Services in New York MILBANK QUARTERLY Chokshi, D. A., Rugge, J., Shah, N. R. 2014; 92 (4): 776-795

  Abstract

  Policy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients.While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves.We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review.The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory care services. From the state government's perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers' understanding of rights and responsibilities. Finally, the regulatory mechanisms employed-from mandatory reporting to licensure to regional planning to the certificate of need-should remain flexible and match the degree of consensus regarding the appropriate regulatory path.Few other states have embarked on a wide-ranging assessment of their regulation of ambulatory care services. By moving toward adopting the regulatory approach described here, New York aims to balance sound oversight with pluralism and innovation in health care delivery.

  View details for DOI 10.1111/1468-0009.12092

  View details for Web of Science ID 000346588500013

  View details for PubMedID 25492604

  View details for PubMedCentralID PMC4266176

• Liberating Data to Transform Health Care New York's Open Data Experience JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Martin, E. G., Helbig, N., Shah, N. R. 2014; 311 (24): 2481-2482

  View details for Web of Science ID 000337757000018

  View details for PubMedID 25058079

• Housing as Health Care - New York's Boundary-Crossing Experiment NEW ENGLAND JOURNAL OF MEDICINE Doran, K. M., Misa, E. J., Shah, N. R. 2013; 369 (25): 2374-2377

  View details for DOI 10.1056/NEJMp1310121

  View details for Web of Science ID 000328586000005

  View details for PubMedID 24350949

• Managing the Human Toll Caused by Seasonal Influenza New York State's Mandate to Vaccinate or Mask JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Caplan, A., Shah, N. R. 2013; 310 (17): 1797-1798

  View details for DOI 10.1001/jama.2013.280633

  View details for Web of Science ID 000326550900008

  View details for PubMedID 24081030

• Should Health Care Systems Become Insurers? JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Shah, N. R., Chokshi, D. A. 2013; 310 (15): 1561-1562

  View details for DOI 10.1001/jama.2013.280015

  View details for Web of Science ID 000325624800015

  View details for PubMedID 24129460

• Managing Potential Conflicts of Interest in State Medicaid Pharmacy and Therapeutics Committees Seeking Harmony JAMA INTERNAL MEDICINE Shah, N. 2013; 173 (5): 344-344

  View details for DOI 10.1001/jamainternmed.2013.4184

  View details for Web of Science ID 000319613100003

  View details for PubMedID 23400627

• Methodological Controversies from Comparative Effectiveness (CE) Studies Using Claims vs. Electronic Health Record (EHR) Data Setoguchi, S., Shah, N., Roy, J., Winkelmayer, W., Glynn, R. WILEY-BLACKWELL. 2010: S16–S17

  View details for Web of Science ID 000209826200038

• Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature. journal of hand surgery Hamou, C., Shah, N. R., DiPonio, L., Curtin, C. M. 2009; 34 (4): 692-699

  Abstract

  We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia.English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes.Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg.More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia.Therapeutic IV.

  View details for DOI 10.1016/j.jhsa.2008.12.002

  View details for PubMedID 19345872

  View details for PubMedCentralID PMC2794307

• Utility of different lipid measures to predict coronary heart disease JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Remick, J., Underberg, J. A., Shah, N. R. 2008; 299 (1): 35-36

  View details for Web of Science ID 000252052000012

  View details for PubMedID 18167402

• Biomarkers for prediction of cardiovascular events NEW ENGLAND JOURNAL OF MEDICINE Mints, G., Shah, N. R. 2007; 356 (14): 1473-1474

  View details for Web of Science ID 000245419600023

  View details for PubMedID 17415904

• Bridging the inferential gap: The electronic health record and clinical evidence HEALTH AFFAIRS Stewart, W. F., Shah, N. R., Selna, M. J., Paulus, R. A., Walker, J. M. 2007; 26 (2): W181-W191

  Abstract

  Most clinical decisions involve bridging the inferential gap: Clinicians are required to "fill in" where they lack knowledge or where no knowledge yet exists. In this context we consider how the inferential gap is a product, in part, of how knowledge is created, the limits to gaining access to such knowledge, and the variable ways in which knowledge is translated into decisions. We consider how electronic health records (EHRs) will help narrow this gap by accelerating the creation of evidence relevant to everyday practice needs and facilitating real-time use of knowledge in practice.

  View details for DOI 10.1377/hlthaff.26.2.w181

  View details for Web of Science ID 000244763500057

  View details for PubMedID 17259202

  View details for PubMedCentralID PMC2670472

• What is the best evidence for making clinical decisions? JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Shah, N. R. 2000; 284 (24): 3127-3127

  View details for Web of Science ID 000165994100025

  View details for PubMedID 11135773

• Randomized, controlled trials, observational studies, and the hierarchy of research designs. NEW ENGLAND JOURNAL OF MEDICINE Concato, J., Shah, N., Horwitz, R. I. 2000; 342 (25): 1887-1892

  Abstract

  In the hierarchy of research designs, the results of randomized, controlled trials are considered to be evidence of the highest grade, whereas observational studies are viewed as having less validity because they reportedly overestimate treatment effects. We used published meta-analyses to identify randomized clinical trials and observational studies that examined the same clinical topics. We then compared the results of the original reports according to the type of research design.A search of the Medline data base for articles published in five major medical journals from 1991 to 1995 identified meta-analyses of randomized, controlled trials and meta-analyses of either cohort or case-control studies that assessed the same intervention. For each of five topics, summary estimates and 95 percent confidence intervals were calculated on the basis of data from the individual randomized, controlled trials and the individual observational studies.For the five clinical topics and 99 reports evaluated, the average results of the observational studies were remarkably similar to those of the randomized, controlled trials. For example, analysis of 13 randomized, controlled trials of the effectiveness of bacille Calmette-Guérin vaccine in preventing active tuberculosis yielded a relative risk of 0.49 (95 percent confidence interval, 0.34 to 0.70) among vaccinated patients, as compared with an odds ratio of 0.50 (95 percent confidence interval, 0.39 to 0.65) from 10 case-control studies. In addition, the range of the point estimates for the effect of vaccination was wider for the randomized, controlled trials (0.20 to 1.56) than for the observational studies (0.17 to 0.84).The results of well-designed observational studies (with either a cohort or a case-control design) do not systematically overestimate the magnitude of the effects of treatment as compared with those in randomized, controlled trials on the same topic.

  View details for Web of Science ID 000087704700007

  View details for PubMedID 10861325

  View details for PubMedCentralID PMC1557642