Gabriel J Escobar

Kaiser Permanente, Oakland, California, United States

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Publications (154)568.29 Total impact

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    ABSTRACT: Abstract Background: Acculturation may influence women's perceptions of health care experiences and may explain the epidemiologic paradox, whereby foreign-born women have lower rates of adverse birth outcomes than United States (US)-born women. We evaluated the relationship between maternal acculturation and specific dimensions of prenatal interpersonal processes of care (IPC) in ethnically diverse women. Methods: Cross-sectional analysis of 1243 multiethnic, postpartum women who delivered at Kaiser Permanente Medical Center in Walnut Creek or San Francisco General Hospital. Women retrospectively reported on their experiences in seven domains of IPC during their pregnancy pertaining to communication, decision making, and interpersonal style. The primary independent variables were four measures of maternal acculturation: birthplace, English language proficiency, the number of years residing in the US, and age at immigration to the US. Generalized linear models, stratified by infant outcome, measured the association between each maternal acculturation measure and specific IPC domains while adjusting for type of health insurance, demographic, and reproductive factors. Results: Approximately 60% of the sample was foreign-born, 36% reported low English proficiency, 43% had resided in the US <10 years, and 35% were age 20 years or older when they immigrated to the US. Over 64% of the women reported having public insurance during pregnancy. In adjusted analyses among women who delivered term and normal birth weight infants, less acculturated women and women with non-private health insurance were more likely to have higher mean IPC scores when compared to more acculturated or US-born women and women with private health insurance, respectively. Conclusion: In a large and ethnically diverse sample of childbearing women in Northern California, less acculturated pregnant women reported better prenatal care experiences than more acculturated and US-born women, another dimension of the "epidemiologic paradox." However, the relationship between acculturation and IPC, as reported during the postpartum period, differed according to infant outcomes.
    Journal of women's health (2002). 06/2014;
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    ABSTRACT: Rationale: Hospitalizations for severe sepsis are common, and a growing number of patients survive to hospital discharge. Nonetheless, little is known about survivors' post-discharge health care utilization. Objectives: To measure inpatient health care use of severe sepsis survivors compared to (1) patients' own pre-sepsis resource use and (2) the resource use of survivors of otherwise similar non-sepsis hospitalizations. Methods: This is an observational cohort study of survivors of severe sepsis and non-sepsis hospitalizations identified from participants in the Health & Retirement Study with linked Medicare claims, 1998-2005. We matched severe sepsis and non-sepsis hospitalizations by demographics, comorbidity burden, pre-morbid disability, hospitalization length, and intensive care use. Measurements and Main Results: Using Medicare claims, we measured patients' utilization of inpatient facilities-hospitals, long-term acute care hospitals, and skilled nursing facilities-in the two years surrounding hospitalization. Severe sepsis survivors spent more days (median 16 (IQR 3-45) vs. 7(0-29), p<0.001) and a higher proportion of days alive (median 9.6% (IQR 1.4%-33.8%) vs. 1.9%(0.0%-7.9%) p<0.001) admitted to facilities in the year after hospitalization, compared to the year prior. The increase in facility-days was similar for non-sepsis hospitalizations. However, the severe sepsis cohort experienced greater post-discharge mortality (44.2% (95%CI:41.3-47.2%) vs. 31.4%(95%CI:28.6%-34.2%) at one year), a steeper decline in days spent at home (difference-in-differences:-38.6 days (95%CI:-50.9--26.3), p<0.001), and a greater increase in the proportion of days alive spent in a facility (difference-in-differences:5.4%(95%CI:2.8%-8.1%), p<0.001). Conclusion: Health care use is markedly elevated after severe sepsis, and post-discharge management may be an opportunity to reduce resource utilization.
    American Journal of Respiratory and Critical Care Medicine 05/2014; · 11.04 Impact Factor
  • JAMA The Journal of the American Medical Association 05/2014; · 29.98 Impact Factor
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    ABSTRACT: Randomized controlled trial evidence supports a restrictive strategy of red blood cell (RBC) transfusion, but significant variation in clinical transfusion practice persists. Patient characteristics other than hemoglobin levels may influence the decision to transfuse RBCs and explain some of this variation. Our objective was to evaluate the role of patient comorbidities and severity of illness in predicting inpatient red blood cell transfusion events.
    BMC Health Services Research 05/2014; 14(1):213. · 1.77 Impact Factor
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    ABSTRACT: BACKGROUND Sepsis, the most expensive cause of hospitalization in the United States, is associated with high morbidity and mortality. However, healthcare utilization patterns following sepsis are poorly understood.OBJECTIVE To identify patient-level factors that contribute to postsepsis mortality and healthcare utilization.DESIGN, SETTING, PATIENTSA retrospective study of sepsis patients drawn from 21 community-based hospitals in Kaiser Permanente Northern California in 2010.MEASUREMENTSWe determined 1-year survival and use of outpatient and facility-based healthcare before and after sepsis and used logistic regression to identify the factors that contributed to early readmission (within 30 days) and high utilization (≥15% of living days spent in facility-based care).RESULTSAmong 6344 sepsis patients, 5479 (86.4%) survived to hospital discharge. Mean age was 72 years with 28.9% of patients aged <65 years. Postsepsis survival was strongly modified by age; 1-year survival was 94.1% for <45 year olds and 54.4% for ≥85 year olds. A total of 978 (17.9%) patients were readmitted within 30 days; only a minority of all rehospitalizations were for infection. After sepsis, adjusted healthcare utilization increased nearly 3-fold compared with presepsis levels and was strongly modified by age. Patient factors including acute severity of illness, hospital length of stay, and the need for intensive care were associated with early readmission and high healthcare utilization; however, the dominant factors explaining variability—comorbid disease burden and high presepsis utilization—were present prior to sepsis admission.CONCLUSION Postsepsis survival and healthcare utilization were most strongly influenced by patient factors already present prior to sepsis hospitalization. Journal of Hospital Medicine 2014;. © 2014 Society of Hospital Medicine
    Journal of Hospital Medicine 04/2014; · 1.40 Impact Factor
  • Patricia Kipnis, Vincent Liu, Gabriel J Escobar
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    ABSTRACT: Risk-adjusted mortality rates are commonly used in quality report cards to compare hospital performance. The risk adjustment depends on models that are assessed for goodness-of-fit using various discrimination and calibration measures. However, the relationship between model fit and the accuracy of hospital comparisons is not well characterized.
    Medical care. 04/2014; 52(4):378-84.
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    ABSTRACT: The absolute neutrophil count and the immature/total neutrophil ratio (I/T) provide information about the risk of early-onset sepsis in newborns. However, it is not clear how to combine their potentially overlapping information into a single likelihood ratio. We obtained electronic records of blood cultures and of complete blood counts with manual differentials drawn <1 hour apart on 66,846 infants ≥34 weeks gestation and <72 hours old born at Kaiser Permanente Northern California and Brigham and Women's Hospitals. We hypothesized that dividing the immature neutrophil count (I) by the total neutrophil count (T) squared (=I/T) would provide a useful summary of the risk of infection. We evaluated the ability of the I/T to discriminate newborns with pathogenic bacteremia from other newborns tested using the area under the receiver operating characteristic curve (c). Discrimination of the I/T (c=0.79; 95% CI: 0.76, 0.82) was similar to that of logistic models with indicator variables for each of 24 combinations of the absolute neutrophil count and the proportion of immature neutrophils (c =0.80, 95% CI: 0.77, 0.83). Discrimination of the I/T improved with age, from 0.70 at <1 hour to 0.87 at ≥4 hours. However, 60% of I/T had likelihood ratios of 0.44 to 1.3, thus only minimally altering the pretest odds of disease. Calculating the I/T could enhance prediction of early onset sepsiss, but the CBC will remain helpful mainly when done at >4 hours of age and when the pretest probability of infection is close to the treatment threshold.
    The Pediatric Infectious Disease Journal 02/2014; · 3.57 Impact Factor
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    ABSTRACT: Adherence to evidence-based recommendations for acute myocardial infarction (AMI) remains unsatisfactory. Quantifying association between using an electronic AMI order set (AMI-OS) and hospital processes and outcomes. Retrospective cohort study. Twenty-one community hospitals. A total of 5879 AMI patients were hospitalized between September 28, 2008 and December 31, 2010. We ascertained whether patients were treated using the AMI-OS or individual orders (a la carte). Dependent process variables were use of evidence-based care; outcome variables were mortality and rehospitalization. Use of individual and combined therapies improved outcomes (eg, 50% lower odds of 30-day mortality for patients with ≥3 therapies). The 3531 patients treated using the AMI-OS were more likely to receive evidence-based therapies (eg, 50% received 5 different therapies vs 36% a la carte). These patients had lower 30-day mortality (5.7% vs 8.5%) than the 2348 treated using a la carte orders. Although AMI-OS patients' predicted mortality risk was lower (3.2%) than that of a la carte patients (4.8%), the association of improved processes and outcomes with the use of the AMI-OS persisted after risk adjustment. For example, after inverse probability weighting, the relative risk for inpatient mortality in the AMI-OS group was 0.67 (95% confidence interval: 0.52-0.86). Inclusion of use of recommended therapies in risk adjustment eliminated the benefit of the AMI-OS, highlighting its mediating effect on adherence to evidence-based treatment. Use of an electronic order set is associated with increased adherence to evidence-based care and better AMI outcomes. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine.
    Journal of Hospital Medicine 02/2014; · 1.40 Impact Factor
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    ABSTRACT: OBJECTIVE:To define a quantitative stratification algorithm for the risk of early-onset sepsis (EOS) in newborns ≥34 weeks' gestation.METHODS:We conducted a retrospective nested case-control study that used split validation. Data collected on each infant included sepsis risk at birth based on objective maternal factors, demographics, specific clinical milestones, and vital signs during the first 24 hours after birth. Using a combination of recursive partitioning and logistic regression, we developed a risk classification scheme for EOS on the derivation dataset. This scheme was then applied to the validation dataset.RESULTS:Using a base population of 608 014 live births ≥34 weeks' gestation at 14 hospitals between 1993 and 2007, we identified all 350 EOS cases <72 hours of age and frequency matched them by hospital and year of birth to 1063 controls. Using maternal and neonatal data, we defined a risk stratification scheme that divided the neonatal population into 3 groups: treat empirically (4.1% of all live births, 60.8% of all EOS cases, sepsis incidence of 8.4/1000 live births), observe and evaluate (11.1% of births, 23.4% of cases, 1.2/1000), and continued observation (84.8% of births, 15.7% of cases, incidence 0.11/1000).CONCLUSIONS:It is possible to combine objective maternal data with evolving objective neonatal clinical findings to define more efficient strategies for the evaluation and treatment of EOS in term and late preterm infants. Judicious application of our scheme could result in decreased antibiotic treatment in 80 000 to 240 000 US newborns each year.
    PEDIATRICS 12/2013; · 4.47 Impact Factor
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    ABSTRACT: The increased vulnerability of late preterm infants is no longer a novel concept in neonatology, with many studies documenting excess morbidity and mortality in these infants during the birth hospitalization. Because outcomes related to gestational age constitute a continuum, it is important to analyze data from the gestational age groups that bookend late preterm infants infants-moderate preterm infants (31-32 weeks) and early term infants (37-38 weeks). This article evaluates hospital readmissions and emergency department visits in the first 30 days after discharge from birth hospitalization in a large cohort of infants greater than or equal to 31 weeks' gestation.
    Clinics in perinatology 12/2013; 40(4):753-75. · 1.54 Impact Factor
  • Gabriel J Escobar
    The Journal of pediatrics 11/2013; 163(5):1528-32. · 4.02 Impact Factor
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    ABSTRACT: Quality Improvement in the ICU ISESSION TYPE: Original Investigation SlidePRESENTED ON: Monday, October 28, 2013 at 01:45 PM - 03:15 PMPURPOSE: To evaluate the outcomes of intensive care unit (ICU) patients with high predicted hospital mortality who survive hospitalizationMETHODS: Among 83,898 ICU episodes between 2008 and 2011 at 21 community hospitals in Kaiser Permanente Northern California, we identified patients with a predicted hospital mortality of >=50% at the time of ICU admission (based on a validated electronic ICU severity score, the eSAPS3). We grouped patients by predicted mortality (50-59%, 60-69%, and >=70%) and hospital survival and compared their baseline and hospital characteristics. We further conducted a focused chart review of all survivors at a single hospital to provide a detailed description of pre- and post-hospital functional status and long-term mortality. We compared groups with analysis of variance and chi-squared tests; we evaluated survival with Kaplan-Meier analysis and log-rank testing.RESULTS: We included a total of 1,700 ICU episodes, among 1,663 patients, in our analysis. Half of patients (50.6%) had a predicted hospital survival of 50-59% with a mean eSAPS3 score of 81 +- 2; roughly one quarter were in the 60-69% and >=70% groups, respectively. Observed mortality closely matched predicted mortality in all groups. Sepsis was the admission diagnosis in more than one-third of all patients. Among patients who survived their hospitalization, estimated survival was 66.5% (95% confidence interval, 62.6%-70.1%) at 6 months, 57.7% (53.5%-61.6%) at 1 year, and 48.7% (43.9%-53.4%) at 2 years. Long-term survival estimates were not different in the 42 patients who underwent focused chart review from a single center (p=0.80). Among these survivors, 84.6% were ambulatory (independently or with a cane/walker) prior to hospitalization. Among those surviving 1 month after discharge, 65.5% were ambulatory; at 6 months, 78.3% of survivors were ambulatory.CONCLUSIONS: Many patients with high predicted mortality on ICU admission die during hospitalization. However, among those that survive, roughly half survive to 2 years and many are ambulatory after hospitalization.CLINICAL IMPLICATIONS: Our findings may help clinicians and families make decisions about aggressive ICU care among severely ill ICU patients.DISCLOSURE: The following authors have nothing to disclose: James Louisell, Gabriel Escobar, Benjamin Turk, Daniel Skully, Danny Sam, Vincent LiuNo Product/Research Disclosure Information.
    Chest 10/2013; 144(4_MeetingAbstracts):399A. · 5.85 Impact Factor
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    ABSTRACT: Rationale Severe sepsis patients without shock or tissue hypoperfusion face substantial mortality, however, treatment guidelines are lacking. Objectives To evaluate the association between intravenous fluid resuscitation, lactate clearance, and mortality in patients with 'intermediate' lactate values of 2 and <4 mmol/L. Methods and Measurements A retrospective study of 9,129 sepsis patients with intermediate lactate values. Interval changes between index lactate values and those at 4, 8, and 12 hours were calculated with corresponding weight-based fluid volumes. Outcomes included lactate change and mortality. Main Results Repeat lactate tests were completed in 94.7% of patients within 12 hours. Hospital and 30-day mortality were 8.2% and 13.3% for patients with lactate clearance; they were 18.7% and 24.7% for those without. Each 10% increase in repeat lactate values was associated with a 9.4% (95% confidence interval [CI], 7.8%-11.1%) increase in the odds of hospital death. Within 4 hours, patients received 32  18 mL/kg of fluid. Each 7.5 mL/kg increase was associated with a 1.3% (95% CI, 0.6%-2.1%) decrease in repeat lactate. Across an unrestricted range, increased fluid was not associated with improved mortality. However, when limited to <45 mL/kg, additional fluid was associated with a trend toward improved survival (OR: 0.92; 95% CI, 0.82-1.03) that was statistically significant among patients with highly concordant fluid records. Conclusions Early fluid administration, below 45 mL/kg, was associated with modest improvements in lactate clearance and potential improvements in mortality. Further study is needed to define treatment strategies in this prevalent and morbid group of sepsis patients.
    Annals of the American Thoracic Society. 09/2013;
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    ABSTRACT: Immunoprophylaxis is the only pharmaceutical intervention for mitigating respiratory syncytial virus (RSV) infection. Patient level data on adherence to American Academy of Pediatrics (AAP) immunoprophylaxis recommendations are limited. This study characterizes adherence to AAP guidelines in privately insured and Medicaid populations.
    Journal of the Pediatric Infectious Diseases Society. 09/2013; 2(3):205-214.
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    ABSTRACT: Prior studies demonstrate the suitability of natural language processing (NLP) for identifying pneumonia in chest radiograph (CXR) reports, however, few evaluate this approach in intensive care unit (ICU) patients. From a total of 194,615 ICU reports, we empirically developed a lexicon to categorize pneumonia-relevant terms and uncertainty profiles. We encoded lexicon items into unique queries within an NLP software application and designed an algorithm to assign automated interpretations ('positive', 'possible', or 'negative') based on each report's query profile. We evaluated algorithm performance in a sample of 2,466 CXR reports interpreted by physician consensus and in two ICU patient subgroups including those admitted for pneumonia and for rheumatologic/endocrine diagnoses. Most reports were deemed 'negative' (51.8%) by physician consensus. Many were 'possible' (41.7%); only 6.5% were 'positive' for pneumonia. The lexicon included 105 terms and uncertainty profiles that were encoded into 31 NLP queries. Queries identified 534,322 'hits' in the full sample, with 2.7 +/- 2.6 'hits' per report. An algorithm, comprised of twenty rules and probability steps, assigned interpretations to reports based on query profiles. In the validation set, the algorithm had 92.7% sensitivity, 91.1% specificity, 93.3% positive predictive value, and 90.3% negative predictive value for differentiating 'negative' from 'positive'/'possible' reports. In the ICU subgroups, the algorithm also demonstrated good performance, misclassifying few reports (5.8%). Many CXR reports in ICU patients demonstrate frank uncertainty regarding a pneumonia diagnosis. This electronic tool demonstrates promise for assigning automated interpretations to CXR reports by leveraging both terms and uncertainty profiles.
    BMC Medical Informatics and Decision Making 08/2013; 13(1):90. · 1.60 Impact Factor
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    ABSTRACT: BACKGROUND: Respiratory syncytial virus (RSV) infection in infancy is associated with subsequent recurrent wheezing. METHODS: A retrospective cohort study examined children born at >=32 weeks gestation between 1996--2004. All children were enrolled in an integrated health care delivery system in Northern California and were followed through the fifth year of life. The primary endpoint was recurrent wheezing in the fifth year of life and its association with laboratory-confirmed, medically-attended RSV infection during the first year, prematurity, and supplemental oxygen during birth hospitalization. Other outcomes measured were recurrent wheezing quantified through outpatient visits, inpatient hospital stays, and asthma prescriptions. RESULTS: The study sample included 72,602 children. The rate of recurrent wheezing in the second year was 5.6% and fell to 4.7% by the fifth year. Recurrent wheezing rates varied by risk status: the rate was 12.5% among infants with RSV hospitalization, 8% among infants 32--33 weeks gestation, and 18% in infants with bronchopulmonary dysplasia. In multivariate analyses, increasing severity of respiratory syncytial virus infection was significantly associated with recurrent wheezing in year 5; compared with children without RSV infection in infancy, children who only had an outpatient RSV encounter had an adjusted odds ratio of 1.38 (95% CI,1.03--1.85), while children with a prolonged RSV hospitalization had an adjusted odds ratio of 2.59 (95% CI, 1.49--4.50). CONCLUSIONS: Laboratory-confirmed, medically attended RSV infection, prematurity, and neonatal exposure to supplemental oxygen have independent associations with development of recurrent wheezing in the fifth year of life.
    BMC Pediatrics 06/2013; 13(1):97. · 1.98 Impact Factor
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    ABSTRACT: : Using a comprehensive inpatient electronic medical record, we sought to develop a risk-adjustment methodology applicable to all hospitalized patients. Further, we assessed the impact of specific data elements on model discrimination, explanatory power, calibration, integrated discrimination improvement, net reclassification improvement, performance across different hospital units, and hospital rankings. : Retrospective cohort study using logistic regression with split validation. : A total of 248,383 patients who experienced 391,584 hospitalizations between January 1, 2008 and August 31, 2011. : Twenty-one hospitals in an integrated health care delivery system in Northern California. : Inpatient and 30-day mortality rates were 3.02% and 5.09%, respectively. In the validation dataset, the greatest improvement in discrimination (increase in c statistic) occurred with the introduction of laboratory data; however, subsequent addition of vital signs and end-of-life care directive data had significant effects on integrated discrimination improvement, net reclassification improvement, and hospital rankings. Use of longitudinally captured comorbidities did not improve model performance when compared with present-on-admission coding. Our final model for inpatient mortality, which included laboratory test results, vital signs, and care directives, had a c statistic of 0.883 and a pseudo-R of 0.295. Results for inpatient and 30-day mortality were virtually identical. : Risk-adjustment of hospital mortality using comprehensive electronic medical records is feasible and permits one to develop statistical models that better reflect actual clinician experience. In addition, such models can be used to assess hospital performance across specific subpopulations, including patients admitted to intensive care.
    Medical care 05/2013; 51(5):446-53. · 3.24 Impact Factor
  • The Journal of allergy and clinical immunology 02/2013; · 12.05 Impact Factor
  • Karen M Puopolo, Gabriel J Escobar
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    ABSTRACT: PURPOSE OF REVIEW: Neonatal early-onset sepsis (EOS) is a very low-incidence, but potentially fatal condition among term and late preterm newborns. EOS algorithms based on risk-factor threshold values result in evaluation and empiric antibiotic treatment of large numbers of uninfected newborns, leading to unnecessary antibiotic exposures and maternal/infant separation. Ideally, risk stratification should be quantitative, employ information conserving strategies, and be readily transferable to modern comprehensive electronic medical records. RECENT FINDINGS: We performed a case-control study of infants born at or above 34 weeks' gestation with blood culture-proven EOS. We defined the relationship of established predictors to the risk of EOS, then used multivariate analyses and split validation to develop a predictive model using objective data. The model provides an estimation of sepsis risk that can identify the same proportion of EOS cases by evaluating fewer infants, as compared with algorithms based on subjective diagnoses and cut-off values for continuous predictors. SUMMARY: An alternative approach to EOS risk assessment based only on objective data could decrease the number of infants evaluated and empirically treated for EOS, compared with currently recommended algorithms. Prospective evaluation is needed to determine the accuracy and safety of using the sepsis risk model to guide clinical decision-making.
    Current opinion in pediatrics 02/2013; · 2.01 Impact Factor
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    ABSTRACT: OBJECTIVE:: Risk adjustment is essential in evaluating the performance of an ICU; however, assigning scores is time-consuming. We sought to create an automated ICU risk adjustment score, based on the Simplified Acute Physiology Score 3, using only data available within the electronic medical record (Kaiser Permanente HealthConnect). DESIGN, SETTING, AND PATIENTS:: The eSimplified Acute Physiology Score 3 was developed by adapting Kaiser Permanente HealthConnect structured data to Simplified Acute Physiology Score 3 criteria. The model was tested among 67,889 first-time ICU admissions at 21 hospitals between 2007 and 2011 to predict hospital mortality. Model performance was evaluated using published Simplified Acute Physiology Score 3 global and North American coefficients; a first-level customized version of the eSimplified Acute Physiology Score 3 was also developed in a 40% derivation cohort and tested in a 60% validation cohort. MEASUREMENTS:: Electronic variables were considered "directly" available if they could be mapped exactly within Kaiser Permanente HealthConnect; they were considered "adapted" if no exact electronic corollary was identified. Model discrimination was evaluated with area under receiver operating characteristic curves; calibration was assessed using Hosmer-Lemeshow goodness-of-fit tests. MAIN RESULTS:: Mean age at ICU admission was 65±17 yrs. Mortality in the ICU was 6.2%; total in-hospital mortality was 11.2%. The majority of Simplified Acute Physiology Score 3 variables were considered "directly" available; others required adaptation based on diagnosis coding, medication records, or procedure tables. Mean eSimplified Acute Physiology Score 3 scores were 45±13. Using published Simplified Acute Physiology Score 3 global and North American coefficients, the eSimplified Acute Physiology Score 3 demonstrated good discrimination (area under the receiver operating characteristic curve, 0.80-0.81); however, it overpredicted mortality. The customized eSimplified Acute Physiology Score 3 score demonstrated good discrimination (area under the receiver operating characteristic curve, 0.82) and calibration (Hosmer-Lemeshow goodness-of-fit chi-square p = 0.57) in the validation cohort. The eSimplified Acute Physiology Score 3 demonstrated stable performance when cohorts were limited to specific hospitals and years. CONCLUSIONS:: The customized eSimplified Acute Physiology Score 3 shows good potential for providing automated risk adjustment in the intensive care unit.
    Critical care medicine 12/2012; · 6.37 Impact Factor

Publication Stats

3k Citations
568.29 Total Impact Points

Institutions

  • 1994–2014
    • Kaiser Permanente
      • Department of Obstetrics and Gynecology
      Oakland, California, United States
  • 2013
    • CSU Mentor
      Long Beach, California, United States
  • 2012
    • Stanford Medicine
      Stanford, California, United States
  • 2003–2012
    • Stanford University
      • • Division of Pulmonary and Critical Care Medicine
      • • Department of Pediatrics
      Stanford, CA, United States
  • 2000–2012
    • University of California, San Francisco
      • • Department of Pediatrics
      • • Department of Obstetrics, Gynecology and Reproductive Sciences
      • • Division of Hospital Medicine
      San Francisco, CA, United States
  • 2011
    • Duke University Medical Center
      • Division of General Internal Medicine
      Durham, NC, United States
    • University of Texas Health Science Center at Houston
      • Department of Pediatrics
      Houston, TX, United States
  • 2008–2011
    • The Children's Hospital of Philadelphia
      • • Department of Pediatrics
      • • Center for Outcomes Research
      Philadelphia, PA, United States
    • March of Dimes Foundation
      White Plains, New York, United States
  • 2005–2011
    • Brigham and Women's Hospital
      • • Department of Newborn Medicine
      • • Department of Medicine
      Boston, MA, United States
  • 2010
    • California Pacific Medical Center Research Institute
      • Department of Pediatrics
      San Francisco, California, United States
    • Duke University
      Durham, North Carolina, United States
    • Albert Einstein College of Medicine
      New York City, New York, United States
    • College of Charleston
      • Department of Mathematics
      Charleston, SC, United States
  • 2006–2008
    • Harvard University
      • Department of Society, Human Development, and Health
      Cambridge, MA, United States
  • 1998–2005
    • Beth Israel Deaconess Medical Center
      • Department of Neonatology
      Boston, MA, United States
  • 1999–2000
    • Dana-Farber Cancer Institute
      Boston, Massachusetts, United States
    • California Department of Health Care Services
      Sacramento, California, United States