Jonathan P Weiner

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States

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Publications (124)565.01 Total impact

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    ABSTRACT: Depression screening is a required part of an initial annual wellness visit (AWV), a benefit for Medicare Part B beneficiaries. It is uncertain whether AWVs will increase depression screening. This study assessed whether patients with an AWV were more likely to be screened for depression than those with a primary care visit. A cross-sectional analysis of electronic health record data was conducted for 4,245 Medicare patients who had at least one primary care visit at one of 34 practices within a large multisite provider network between September 2010 and August 2012. Quota sampling was used so that half of the participants had an AWV and half had a randomly selected primary care visit during the study period (the index visit). Multilevel logistic regressions were used to determine whether patients with an AWV had increased odds of depression screening compared with patients with a primary care visit, after adjustment for physician and clinic clustering. Fifteen percent of patients with non-AWVs and 10% of patients with AWVs received depression screening. After accounting for clustering, there was no statistically significant difference in depression screening by visit type. There was a strong site effect, with one site conducting screening during 78% of AWVs and 82% of non-AWVs. Six sites screened none of their patients. Overall, depression screening during the index AWV was uncommon. By itself, the AWV benefit does not appear to be a strong enough incentive to increase depression screening.
    Psychiatric services (Washington, D.C.) 07/2015; DOI:10.1176/appi.ps.201400524 · 1.99 Impact Factor
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    ABSTRACT: To evaluate conformance to depression screening, management, and outcome quality indicators and to evaluate individual characteristics associated with conformance to these indicators. Cross-sectional study using electronic health record (EHR) data. Thirty-four clinics in one healthcare system. Medicare beneficiaries aged 65 and older with at least one primary care visit between September 2010 and August 2012 (N = 5,000). Seven measures, current as of 2013, were found for which all the necessary specifications were available in the EHR: general screening, screening within 4 months of diagnosis, screening after stroke, screening after heart disease, depression reassessment, depression response, and depression remission. Multilevel logistic regression analyses were used to determine factors associated with conformance. Screening for depression in Medicare beneficiaries was low (17%). Conformance to measures varied from 10% for the depression response measure to 77% for the depression remission measure. In the adjusted regression analyses for the general screening (adjusted odds ratio (AOR) = 1.45, 95% confidence interval (CI) = 1.01-2.08), depression reassessment (AOR = 4.19, 95% CI = 1.16-15.19), and screening after heart disease (AOR = 5.57, 95% CI = 1.37-22.57) measures, black participants were more likely to be given care that conformed to the numerator criteria than white participants. A strong site effect was found, with 90% of the depression screens being administered at three sites. Only a small proportion of Medicare beneficiaries received the recommended screening and follow-up care needed to conform to the quality measures for depression in the primary care setting. Further evaluation of measures of depression care should be conducted before these measures are implemented widely. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.
    Journal of the American Geriatrics Society 06/2015; 63. DOI:10.1111/jgs.13483 · 4.22 Impact Factor
  • Craig E Pollack · Klaus W Lemke · Eric Roberts · Jonathan P Weiner
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    ABSTRACT: With the goal of improving clinical efficiency and effectiveness, programs to enhance care coordination are a major focus of health care reform. To examine whether "care density"-a claims-based measure of patient sharing by office-based physicians-is associated with measures of quality. Care density is a proxy measure that may reflect how frequently a patient's doctors collaborate. Cohort study using administrative databases from 3 large commercial insurance plans. A total of 1.7 million adult patients; 31,675 with congestive heart failure, 78,530 with chronic obstructive pulmonary disease, and 240,378 with diabetes. Care density was assessed in 2008. Prevention Quality Indicators (PQIs), 30-day readmissions, and Healthcare Effectiveness Data and Information Set quality indicators were measured in the following year. Among all patients, we found that patients with the highest care density density-indicating high levels of patient sharing among their office-based physicians-had significantly lower rates of adverse events measured as PQIs compared with patients with low-care density (odds ratio=0.88; 95% confidence interval, 0.85-0.92). A significant association between care density and PQIs was also observed for patients with diabetes mellitus but not congestive heart failure or chronic obstructive pulmonary disease. Diabetic patients with higher care density scores had significantly lower odds of 30-day readmissions (odds ratio=0.68, 95% confidence interval, 0.48-0.97). Significant associations were observed between care density and Healthcare Effectiveness Data and Information Set measures although not always in the expected direction. In some settings, patients whose doctors share more patients had lower odds of adverse events and 30-day readmissions.
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    Emily R Adrion · John Aucott · Klaus W Lemke · Jonathan P Weiner
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    ABSTRACT: Lyme disease is the most frequently reported vector borne infection in the United States. The Centers for Disease Control have estimated that approximately 10% to 20% of individuals may experience Post-Treatment Lyme Disease Syndrome - a set of symptoms including fatigue, musculoskeletal pain, and neurocognitive complaints that persist after initial antibiotic treatment of Lyme disease. Little is known about the impact of Lyme disease or post-treatment Lyme disease symptoms (PTLDS) on health care costs and utilization in the United States. 1) to examine the impact of Lyme disease on health care costs and utilization, 2) to understand the relationship between Lyme disease and the probability of developing PTLDS, 3) to understand how PTLDS may impact health care costs and utilization. This study utilizes retrospective data on medical claims and member enrollment for persons aged 0-64 years who were enrolled in commercial health insurance plans in the United States between 2006-2010. 52,795 individuals treated for Lyme disease were compared to 263,975 matched controls with no evidence of Lyme disease exposure. Lyme disease is associated with $2,968 higher total health care costs (95% CI: 2,807-3,128, p<.001) and 87% more outpatient visits (95% CI: 86%-89%, p<.001) over a 12-month period, and is associated with 4.77 times greater odds of having any PTLDS-related diagnosis, as compared to controls (95% CI: 4.67-4.87, p<.001). Among those with Lyme disease, having one or more PTLDS-related diagnosis is associated with $3,798 higher total health care costs (95% CI: 3,542-4,055, p<.001) and 66% more outpatient visits (95% CI: 64%-69%, p<.001) over a 12-month period, relative to those with no PTLDS-related diagnoses. Lyme disease is associated with increased costs above what would be expected for an easy to treat infection. The presence of PTLDS-related diagnoses after treatment is associated with significant health care costs and utilization.
    PLoS ONE 02/2015; 10(2):e0116767. DOI:10.1371/journal.pone.0116767 · 3.23 Impact Factor
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    Hadi Kharrazi · Jonathan P Weiner
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    ABSTRACT: Rising health information technology (HIT) adoption and the increasing interoperability of health data have propelled the role of IT in community-wide health transformations. Disseminating the challenges and opportunities that the early adopters of community-wide HIT interventions have experienced is critical for empowering the growing demand for community-based health systems. This special issue of eGEMs addresses that need. This issue includes a variety of community-based HIT projects covering topics such as governance, informatics, and learning health systems. These projects represent a diverse set of stakeholders, a wide selection of data sources, and multiple information platforms to collate or exchange data. We hope that this special issue of eGEMs will be the first of several future issues dedicated to community-wide HIT transformations.
    10/2014; 2(3):1117. DOI:10.13063/2327-9214.1117
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    ABSTRACT: Health care quality is frequently described with measures representing the overall performance of a health care system. Despite the growing attention to overuse of health care resources, there is little experience with aggregate measures of overuse. To identify a set of possible indicators of overuse that can be operationalized with claims data and to describe variation in these indicators across the hospital referral regions (HRRs). Using an environmental scan, we identified published descriptions of overused procedures. We assessed each procedure's feasibility for measurement with claims and developed algorithms for occurrences of procedures in patients unlikely to benefit. Using a 5% sample of Medicare claims from 2008, we calculated summary statistics to illustrate variance in the use across HRRs. A total of 613 procedures were identified as overused; 20 had abundant frequency and variance to be possible measures of systematic overuse. These included 13 diagnostic tests, 2 tests for screening, 1 for monitoring, and 4 therapeutic procedures. The usage varied markedly across HRRs. For illustration, 1 HRR used computed tomography for rhinosinusitis diagnosis in 80 of 1000 beneficiaries (mean usage across HRRs was 14/1000). Among 1,451,142 beneficiaries, 14% had at least one overuse event (range, 8.4%-27%). We identified a set of overused procedures that may be used as measures of overuse and that demonstrate significant variance in their usage. The implication is that an index of overuse might be built from these indicators that would reveal systematic patterns of overuse within regions. Alternatively, these indicators may be valuable in the quality improvement efforts.
    Medical care 12/2013; 52(2). DOI:10.1097/MLR.0000000000000052 · 2.94 Impact Factor
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    Jonathan P Weiner · Susan Yeh · David Blumenthal
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    ABSTRACT: Arguably, few factors will change the future face of the American health care workforce as widely and dramatically as health information technology (IT) and electronic health (e-health) applications. We explore how such applications designed for providers and patients will affect the future demand for physicians. We performed what we believe to be the most comprehensive review of the literature to date, including previously published systematic reviews and relevant individual studies. We estimate that if health IT were fully implemented in 30 percent of community-based physicians' offices, the demand for physicians would be reduced by about 4-9 percent. Delegation of care to nurse practitioners and physician assistants supported by health IT could reduce the future demand for physicians by 4-7 percent. Similarly, IT-supported delegation from specialist physicians to generalists could reduce the demand for specialists by 2-5 percent. The use of health IT could also help address regional shortages of physicians by potentially enabling 12 percent of care to be delivered remotely or asynchronously. These estimated impacts could more than double if comprehensive health IT systems were adopted by 70 percent of US ambulatory care delivery settings. Future predictions of physician supply adequacy should take these likely changes into account.
    Health Affairs 11/2013; 32(11):1998-2004. DOI:10.1377/hlthaff.2013.0680 · 4.64 Impact Factor
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    ABSTRACT: Evidence regarding the impact of nurse practitioners (NPs) compared to physicians (MDs) on health care quality, safety, and effectiveness was systematically reviewed. Data from 37 of 27,993 articles published from 1990-2009 were summarized into 11 aggregated outcomes. Outcomes for NPs compared to MDs (or teams without NPs) are comparable or better for all 11 outcomes reviewed. A high level of evidence indicated better serum lipid levels in patients cared for by NPs in primary care settings. A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs.
    The Journal for Nurse Practitioners 09/2013; 9(8):492-500.e13. DOI:10.1016/j.nurpra.2013.07.004
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    ABSTRACT: Background: Because laboratory test results are less available to researchers than claims data, a claims-based indicator of diabetes improvement would be valuable. Objectives: To determine whether a decrease in medication use for diabetes parallels clinical improvement in glycemic control. Study Design: This was a retrospective cohort study using up to 3.5 years of pharmacy and laboratory data from 1 private insurer. Data included 104 patients with diabetes who underwent bariatric surgery and had at least 1 glycated hemoglobin (A1C) test before and after surgery. Methods: We assigned each A1C test to a 90-day interval before or after surgery. Medication availability was noted for the midpoint of the interval (on insulin, on oral medications, count of medications). Each subject could contribute 1 presurgery and up to 3 postsurgery observations. We recorded the changes in A1C test results and medication use from the presurgery to the postsurgery period. Using the A1C test as the reference standard, positive and negative predictive values of medication-based indicators were calculated. Results: After bariatric surgery, A1C test values decreased by more than 1% and the count of unique medications decreased by 0.6. All 3 medication-based indicators had high positive predictive values (0.85) and low negative predictive values (0.20), and count of medications had better performance than the other indicators. Conclusions: Without clinical information, a decrease in use of medications can serve as a proxy for clinical improvement. Validation of results in other settings is needed.
    The American journal of managed care 07/2013; 19(7):572-8. · 2.17 Impact Factor
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    ABSTRACT: OBJECTIVE: Negative interactions with healthcare providers may lead patients to switch physicians or "doctor shop." We hypothesized that overweight and obese patients would be more likely to doctor shop, and as a result, have increased rates of emergency department (ED) visits and hospitalizations as compared to normal weight nonshoppers. DESIGN AND METHODS: We combined claims data from a health plan in one state with information from beneficiaries' health risk assessments. The primary outcome was "doctor shopping," which we defined as having outpatient claims with ≥5 different primary care physicians (PCPs) during a 24-month period. The independent variable was standard NIH categories of weight by BMI. We performed multivariate logistic regression to evaluate the association between weight categories and doctor shopping. We conducted multivariate zero-inflated negative binominal regression to evaluate the association between weight-doctor shopping categories with counts of ED visits and hospitalizations. RESULTS: Of the 20,726 beneficiaries, the mean BMI was 26.3 kg m(-2) (SD 5.1), mean age was 44.4 years (SD 11.1) and 53% were female. As compared to normal weight beneficiaries, overweight beneficiaries had 23% greater adjusted odds of doctor shopping (OR 1.23, 95%CI 1.04-1.46) and obese beneficiaries had 52% greater adjusted odds of doctor shopping (OR 1.52, 95%CI 1.26-1.82). As compared to normal weight non-shoppers, overweight and obese shoppers had higher rates of ED visits (IRR 1.85, 95%CI 1.37-2.45; IRR 1.83, 95%CI 1.34-2.50, respectively), which persisted during within weight group comparisons (Overweight IRR 1.50, 95%CI 1.10-2.03; Obese IRR 1.54, 95%CI 1.12-2.11). CONCLUSION: Frequently changing PCPs may impair continuity and result in increased healthcare utilization.
    Obesity 07/2013; 21(7). DOI:10.1002/oby.20189 · 4.39 Impact Factor
  • Christine Butorff · Sean R Tunis · Jonathan P Weiner
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    ABSTRACT: Objectives: One of the main goals of the Affordable Care Act (ACA) is to control the costs of US healthcare. Channeling patients toward more effective services is one of many approaches being used to control costs while improving health outcomes. This paper reviews value-based insurance design (VBID) concepts and discusses options for states to encourage these designs in the new health insurance exchanges (HIEs). Methods: We reviewed the literature on VBID as well as the text of the ACA for descriptions of how VBID might be encouraged through the new state health insurance exchanges. Results: States, under healthcare reform, are allowed to promote the use of VBID designs in their exchanges. There are 4 broad approaches a state HIE could pursue with regard to VBID, ranging from establishing a process for recommending high- or low-value services and requiring plans to adhere to the recommendations, to offering no guidance to plans. The evidence surrounding how well VBID designs work is growing, but it is still limited. To date there is no evidence that reducing or eliminating copays for preventive services cuts costs in the long term. However, modeling does suggest the potential for such long-term savings,so states should proceed with caution. Conclusions: Modifying copays, even in small amounts, can send signals to patients about the relative value of drugs and services. However, long-term savings will likely result from higher copays on low-value services. The leadership of each exchange has a unique opportunity to reshape the insurance benefit landscape in its state to improve value and invest in prevention.
    The American journal of managed care 07/2013; 19(7):593-600. · 2.17 Impact Factor
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    ABSTRACT: To develop and provide initial validation for a multivariate, claims-based prediction model for disability status (DS), a proxy measure of performance status (PS), among older adults. The model was designed to augment information on health status at the point of cancer diagnosis in studies using insurance claims to examine cancer treatment and outcomes. We used data from the 2001-2005 Medicare Current Beneficiary Survey (MCBS), with observations randomly split into estimation and validation subsamples. We developed an algorithm linking self-reported functional status measures to a DS scale, a proxy for the Eastern Cooperative Oncology Group (ECOG) PS scale. The DS measure was dichotomized to focus on good [ECOG 0-2] versus poor [ECOG 3-4] PS. We identified potential claims-based predictors, and estimated multivariate logistic regression models, with poor DS as the dependent measure, using a stepwise approach to select the optimal model. Construct validity was tested by determining whether the predicted DS measure generated by the model was a significant predictor of survival within a validation sample from the MCBS. One-tenth of beneficiaries met the definition for poor DS. The base model yielded high sensitivity (0.79) and specificity (0.92); positive predictive value=48.3% and negative predictive value=97.8%, c-statistic=0.92 and good model calibration. Adjusted poor claims-based DS was associated with an increased hazard of death (HR=3.53, 95% CI 3.18, 3.92). The ability to assess DS should improve covariate control and reduce indication bias in observational studies of cancer treatment and outcomes based on insurance claims.
    Journal of Geriatric Oncology 04/2013; 4(2):157-165. DOI:10.1016/j.jgo.2012.12.005 · 1.15 Impact Factor
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    ABSTRACT: IMPORTANCE Acute pancreatitis has significant morbidity and mortality. Previous studies have raised the possibility that glucagonlike peptide 1 (GLP-1)-based therapies, including a GLP-1 mimetic (exenatide) and a dipeptidyl peptidase 4 inhibitor (sitagliptin phosphate), may increase the risk of acute pancreatitis. OBJECTIVE To test whether GLP-1-based therapies such as exenatide and sitagliptin are associated with an increased risk of acute pancreatitis. We used conditional logistic regression to analyze the data. DESIGN Population-based case-control study. SETTING A large administrative database in the United States from February 1, 2005, through December 31, 2008. PARTICIPANTS Adults with type 2 diabetes mellitus aged 18 to 64 years. We identified 1269 hospitalized cases with acute pancreatitis using a validated algorithm and 1269 control subjects matched for age category, sex, enrollment pattern, and diabetes complications. MAIN OUTCOME MEASURE Hospitalization for acute pancreatitis. RESULTS The mean age of included individuals was 52 years, and 57.45% were male. Cases were significantly more likely than controls to have hypertriglyceridemia (12.92% vs 8.35%), alcohol use (3.23% vs 0.24%), gallstones (9.06% vs 1.34), tobacco abuse (16.39% vs 5.52%), obesity (19.62% vs 9.77%), biliary and pancreatic cancer (2.84% vs 0%), cystic fibrosis (0.79% vs 0%), and any neoplasm (29.94% vs 18.05%). After adjusting for available confounders and metformin hydrochloride use, current use of GLP-1-based therapies within 30 days (adjusted odds ratio, 2.24 [95% CI, 1.36-3.68]) and recent use past 30 days and less than 2 years (2.01 [1.37-3.18]) were associated with significantly increased odds of acute pancreatitis relative to the odds in nonusers. CONCLUSIONS AND RELEVANCE In this administrative database study of US adults with type 2 diabetes mellitus, treatment with the GLP-1-based therapies sitagliptin and exenatide was associated with increased odds of hospitalization for acute pancreatitis.
    JAMA Internal Medicine 02/2013; 173(7):1-6. DOI:10.1001/jamainternmed.2013.2720 · 13.25 Impact Factor
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    ABSTRACT: IMPORTANCE Bariatric surgery is a well-documented treatment for obesity, but there are uncertainties about the degree to which such surgery is associated with health care cost reductions that are sustained over time. OBJECTIVE To provide a comprehensive, multiyear analysis of health care costs by type of procedure within a large cohort of privately insured persons who underwent bariatric surgery compared with a matched nonsurgical cohort. DESIGN Longitudinal analysis of 2002-2008 claims data comparing a bariatric surgery cohort with a matched nonsurgical cohort. SETTING Seven BlueCross BlueShield health insurance plans with a total enrollment of more than 18 million persons. PARTICIPANTS A total of 29 820 plan members who underwent bariatric surgery between January 1, 2002, and December 31, 2008, and a 1:1 matched comparison group of persons not undergoing surgery but with diagnoses closely associated with obesity. MAIN OUTCOME MEASURES Standardized costs (overall and by type of care) and adjusted ratios of the surgical group's costs relative to those of the comparison group. RESULTS Total costs were greater in the bariatric surgery group during the second and third years following surgery but were similar in the later years. However, the bariatric group's prescription and office visit costs were lower and their inpatient costs were higher. Those undergoing laparoscopic surgery had lower costs in the first few years after surgery, but these differences did not persist. CONCLUSIONS AND RELEVANCE Bariatric surgery does not reduce overall health care costs in the long term. Also, there is no evidence that any one type of surgery is more likely to reduce long-term health care costs. To assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings.
    JAMA SURGERY 02/2013; 148(6):1-8. DOI:10.1001/jamasurg.2013.1504 · 4.30 Impact Factor
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    ABSTRACT: OBJECTIVES: . To determine if access to medical services differed by regions and to demonstrate the extent of the differences of adopting a claims-based risk-adjustment system versus a demographic model for regional resource allocation. METHODS: . The claims of a 1% random sample of Taiwan's National Health Insurance enrollees (N = 173 175) in 2002 was used. The number of visits and morbidity-adjusted resource consumption were calculated individually then collapsed regionally. Regional expected resource allocation was compared with actual consumption. RESULTS: . After controlling for diagnosis-based health measures, the average numbers of visits were stable across regions. Two models were consistent in showing over- or underutilization; the overall difference between two models in resource allocation was 5.8% at the district level. We observed strong urban overutilization and rural underutilization. CONCLUSIONS: . Access to medical services is similar across regions. The adoption of a diagnosis-based model over a demographic-adjusted budgeting method would affect resource allocation considerably.
    Asia-Pacific Journal of Public Health 01/2013; 27(2). DOI:10.1177/1010539512471073 · 1.11 Impact Factor
  • 01/2013; DOI:10.12688/f1000research.2-145.v1
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    ABSTRACT: Objectives: To test the validity of the adapted Diabetes Complications Severity Index (aDCSI), which does not include laboratory test results, as an indicator of diabetes severity. Study Design: Retrospective cohort study using 4 years of claims data from 7 health insurance plans. Methods: Individuals with diabetes mellitus and continuous enrollment were study subjects (N = 138,615). The 2 independent variables-the aDCSI score (sum of 7 diabetes complications graded by severity as 0, 1, or 2; range 0-13) and the aDCSI diabetes complication count (sum of 7 diabetes complications without severity grading; range 0-7)-were generated using only claims data. We evaluated the numbers of hospitalizations attributable to the aDCSI with Poisson regression models, both categorically and linearly. Results: The aDCSI score (risk ratio 1.39 to 6.10 categorically and 1.41 linearly) and diabetes complication count (risk ratio 1.67 to 9.11 categorically and 1.65 linearly) were both significantly positively associated with the number of hospitalizations over a 4-year period. Risk ratios from the aDCSI score were very similar to the risk ratios previously reported for the Diabetes Complications Severity Index (DCSI); the absolute difference between risk ratios ranged from 0.01 to 1.6 categorically and was 0.05 linearly. Conclusions: The aDCSI is a good measure of diabetes severity, given its ability to explain hospitalizations and its similar performance to the DCSI.
    The American journal of managed care 11/2012; 18(11):721-6. · 2.17 Impact Factor
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    ABSTRACT: The objective of this study was to determine the prevalence of work limitations and their relationship to morbidity burden among academic health center employees with diabetes. Employees with diabetes were surveyed via Internet and mail using the Work Limitations Questionnaire. Morbidity burden was measured using the Adjusted Clinical Groups methodology. Seventy-two percent of the employees with diabetes had a work limitation. Adjusted odds ratios for overall, physical, time, and output limitations were 1.81, 2.27, 2.13, and 2.14, respectively. Morbidity burden level is an indicator of work limitations in employees with diabetes and can be used to identify employees who may benefit from specialized services aimed at addressing their work limitations associated with diabetes.
    10/2012; 60(10):425-434. DOI:10.3928/21650799-20120917-38
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    ABSTRACT: This article examines the potential benefits of enhanced use of advanced practice registered nurses (APRNs) given health care workforce projections that predict an inadequate supply of certain types of providers. The conclusions of a systematic review comparing the effectiveness of care provided by APRNs with that of physicians alone or teams without APRNs indicate the viability of this approach. Allowing APRNs to assume roles that take full advantage of their educational preparation could mitigate the shortage of primary care physicians and improve care processes. The development of health care policy should be guided by patient-centric evidence rather than how care has been delivered in the past.
    Policy Politics &amp Nursing Practice 08/2012; 13(2):81-9. DOI:10.1177/1527154412456299

Publication Stats

3k Citations
565.01 Total Impact Points

Institutions

  • 1990–2015
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Health Policy and Management
      Baltimore, Maryland, United States
  • 1987–2013
    • Johns Hopkins University
      • Department of Medicine
      Baltimore, Maryland, United States
    • American University Washington D.C.
      Washington, Washington, D.C., United States
  • 2011
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
  • 2009
    • The Children's Hospital of Philadelphia
      • Department of Pediatrics
      Philadelphia, PA, United States
  • 2003
    • Park Nicollet Health Services
      Minneapolis, Minnesota, United States
  • 2002
    • HealthPartners Institute for Education and Research
      Bloomington, Minnesota, United States
  • 1997
    • Case Western Reserve University
      • Department of Epidemiology and Biostatistics
      Cleveland, OH, United States
  • 1996
    • University of Pittsburgh
      • Department of Psychiatry
      Pittsburgh, PA, United States
  • 1995
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1994–1995
    • Brandeis University
      • Schneider Institute for Health Policy
      Waltham, MA, United States