- Pediatric Gastroenterology
Clinical Assistant Professor, Pediatrics - Gastroenterology
Residency:Stanford Medicine Pediatric Residency (2010) CA
Internship:Stanford Medicine Pediatric Residency (2008) CA
Board Certification: Pediatric Gastroenterology, American Board of Pediatrics (2015)
Fellowship:Stanford University - Gastroenterology Department of Pediatrics (2014) CA
Board Certification: Pediatrics, American Board of Pediatrics (2010)
Medical Education:Robert Wood Johnson Med School (2007) NJ
Fellowship, Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition (2014)
Fellowship, Clinical Excellence Research Center at Stanford University, Health care innovation (2014)
Residency, Lucile Packard Children’s Hospital at Stanford, Pediatrics (2010)
MD, University of Medicine & Dentistry of New Jersey - Robert Wood Johnson Medical School, Medicine (2007)
MPH, Mailman School of Public Health at Columbia University, Health Policy and Management (2002)
BA, University of Pennsylvania, International Relations (1999)
Current Research and Scholarly Interests
My research focuses on improving health care delivery systems for children, adolescents and young adults with chronic illness and their families. I have particular interests in the development of chronic disease self-management skills, assessment of patient reported outcomes, the transition from pediatric to adult-oriented health care, and comprehensive programs to support families caring for a child with chronic illness.
Diabetes Device Use in Adults With Type 1 Diabetes: Barriers to Uptake and Potential Intervention Targets.
2017; 40 (2): 181-187
Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target.We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices.Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one's body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6-26.0 vs. 21.4-24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18-25 years) had the lowest CGM (26% vs. 40-48%) and insulin pump (64% vs. 69-77%) uptake, highest diabetes distress (2.2 vs. 1.8-2.1), and highest HbA1c levels (8.3% [67 mmol/mol] vs. 7.2-7.4% [55-57 mmol/mol]).Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA1c compared with older age-groups, they should be the focus of future interventions to increase device use.
View details for DOI 10.2337/dc16-1536
View details for PubMedID 27899489
Spanish and English Language Symposia to Enhance Activation in Pediatric Inflammatory Bowel Disease.
Journal of pediatric gastroenterology and nutrition
2016; 63 (5): 508-511
Patient activation is an important consideration for improved health outcomes in the management of chronic diseases. Limited English proficiency (LEP) among patients and primary care providers has been shown to be a predictor for worse health across disease states. We aimed to determine the baseline patient activation measure (PAM) among Spanish-speaking (SP) and English-speaking (ES) pediatric IBD patients and parents, and to describe the feasibility and efficacy of a novel peer-group education symposium designed to enhance patient activation as measured with the PAM.Two separate half-day educational symposia in either Spanish or English were presented and moderated by 2 native Spanish-speaking physicians. Content for each of the presentations were highly standardized and interactive, designed to address each of the activation domains (self-management, collaboration with a health care provider, maintenance of function and prevention of disease exacerbation, and appropriate access to high-quality care). Descriptive statistics were used to describe changes between pre- and post-symposium PAM trends.11 primarily SP and 21 ES families participated in their respective symposium. Paired pre- and post-PAM scores were available from 24 pediatric IBD patients (8 SP; 16 ES) and 41 parents (15 SP; 26 ES). The mean age for SP and ES patients was 11.6 and 12.0 years, and female gender in 80% and 62%, respectively. Paired pre- and post-PAM scores for all participants (n = 65) were analyzed. PAM scores uniformly increased in all 4 groups after the symposia (SP-patients 59.1 to 70.3, P = 0.05; SP-parents 69.8 to 75.2, P = 0.2; ES-patients 59.9 to 64.0, P = 0.08; ES-parents 61.9 to 69.1, P = 0.002), although only the ES-parents group had sufficient sample size (n = 26) to achieve statistical significance. The overall cohort had an aggregate increase from pre-PAM of 62.9 (SD 14.5) to post-PAM of 69.4 (SD 13.9) (<0.001).We describe a novel peer-group educational symposium presented in Spanish and English languages to increase patient and parent activation in pediatric IBD patients and their care-giving parents. The use of PAM to assess levels of activation appears to be feasible and effective in these groups.
View details for PubMedID 27031374
Transitions in Pediatric Gastroenterology: Results of a National Provider Survey.
Journal of pediatric gastroenterology and nutrition
2016; 63 (5): 488-493
Transition and transfer to adult-oriented health care is an important yet challenging task for adolescents and young adults with chronic medical conditions. Transition practices vary widely, but a paucity of data makes determination of best practices difficult. We describe North American pediatric gastroenterologists' preferences and current transition practice patterns and explore whether experience affects providers' perspectives.An on-line survey was distributed via email to members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Participation was voluntary and answers were anonymous. Quantitative and qualitative analysis was performed.Almost three quarters of the 175 respondents describe providing transition or self-care management education, but only 23% use structured readiness assessments. Most respondents (88%) report having age cut-offs above which they no longer accept new referrals, with the most common age being 18 years (57%). One third report the ability to provide age-appropriate care to patients over age 21 years. Only 6% indicate that their practice or institution should provide care for individuals over age 25 years. Many (63%) indicate that their practice or institution has a policy regarding age of transfer, but most (79%) are flexible. Provider preferences for triggers to transfer to adult care diverge widely between age, milestones and comorbidities. Overall, parent (81%) and patient (74%) attachment to pediatric healthcare providers are cited as the most common barriers to transition.Preferences and practices surrounding transition preparation and transfer to adult care vary widely, reflecting continued uncertainty regarding optimal transition strategies.
View details for PubMedID 27027904
Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness.
Healthcare (Amsterdam, Netherlands)
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
- Legislative advocacy: evaluation of a grand rounds intervention for pediatricians. Academic pediatrics 2014; 14 (2): 181-185
Geographical Rural Status and Health Outcomes in Pediatric Liver Transplantation: An Analysis of 6 Years of National United Network of Organ Sharing Data
JOURNAL OF PEDIATRICS
2013; 162 (2): 313-?
To determine whether children in rural areas have worse health than children in urban areas after liver transplantation (LT).We used urban influence codes published by the US Department of Agriculture to categorize 3307 pediatric patients undergoing LT in the United Network of Organ Sharing database between 2004 and 2009 as urban or rural. Allograft rejection, patient death, and graft failure were used as primary outcome measures of post-LT health. Pediatric end-stage liver disease/model of end-stage liver disease scores >20 was used to measure worse pre-LT health.In a multivariate analysis, we found greater rates of allograft rejection within 6 months of LT (OR 1.27; 95% CI 1.05-1.53) and a lower occurrence of posttransplantation lymphoproliferative disorder (OR 0.64; 95% CI 0.41-0.99) in patients in rural areas. The difference in allograft rejection was eliminated at 1 year of LT (OR 1.18; 95% CI 0.98-1.42). Rural location did not impact other outcome measures.We conclude that rural location makes a negative impact on patient health within the first 6 months of LT by increasing the risk for allograft rejection, although patients in rural areas may have lower rates of developing posttransplantation lymphoproliferative disorder. Long-term adverse health effects were not seen.
View details for DOI 10.1016/j.jpeds.2012.07.015
View details for Web of Science ID 000313579900021
View details for PubMedID 22914224
Effects of rural status on health outcomes in pediatric liver transplantation: A single center analysis of 388 patients
2011; 15 (3): 300-305
Rural status of patients may impact health before and after pediatric LT. We used UI codes published by the USDA to stratify patients as urban or rural depending county residence. A total of 388 patients who had LT and who met criteria were included. Rejection, PTLD, and survival were used as primary outcome measures of post-LT health. UNOS Status 1 and PELD/MELD scores >20 were used as secondary outcome measures of poorer pre-LT health. Logistic regression models were run to determine associations. We did not find any statistically significant differences in pre- or post-LT outcomes with respect to rurality. Among rural patients, there was a general trend for decreased incidence of rejection (25.0% vs. 33.4%; OR 0.64, 95% CI 0.29-1.44), increased risk of PTLD (5.6% vs. 3.4%; OR 1.86, 95% CI 0.36-3.31), and decreased survival (OR 0.85, 95% CI 0.34-2.13) after LT. Rural patients also tended to be sicker at the time of LT than patients from urban areas, with increased proportion of Status 1 (OR 1.17, 95% CI 0.51-2.70) and PELD/MELD scores >20 (OR 1.20, 95% CI 0.59-2.45). From a single center experience, we conclude that rurality did not significantly affect health outcomes after LT, although a larger study may validate the general trends that rural patients may have decreased rejection, increased PTLD, and mortality, and be in poorer health at the time of LT.
View details for DOI 10.1111/j.1399-3046.2010.01452.x
View details for Web of Science ID 000289628100018
View details for PubMedID 21450010