Karl A Lorenz

CSU Mentor, Long Beach, California, United States

Are you Karl A Lorenz?

Claim your profile

Publications (105)385.74 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention. Methods: We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC. Results: We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38). Conclusions: Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.
    Journal of palliative medicine. 12/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: We partnered with patients, families, and palliative care clinicians to develop an integrated urology-palliative care clinic for patients with metastatic cancer. We assessed clinician satisfaction with a multidisciplinary palliative care clinic model.
    The American journal of hospice & palliative care 10/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Early and repeated patient-provider conversations about advance care planning (ACP) are now widely recommended. We sought to characterize barriers and strategies for realizing an iterative model of ACP patient-provider communication.
    The American journal of hospice & palliative care 07/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Patient-reported data may provide valuable information for oncology quality measurement. We evaluated applying patient-reported data from the Cancer Care Outcomes Research and Surveillance Consortium national study to quality indicators addressing supportive oncology domains. We analyzed surveys including validated instruments for symptoms and care planning from 4,174 patients newly diagnosed with lung or colorectal cancer. We adapted existing supportive oncology indicators for use with patient-reported data from Cancer Quality-ASSIST and the American Society of Clinical Oncology Quality Oncology Practice Initiative. Where feasible, we examined indicators using medical record data for comparison purposes. Using patient-reported data, the percentage of patients meeting indicator criteria for screening ranged from 74% (significant depressive symptoms) to 93% (pain, nausea/vomiting). The percentage meeting indicator criteria for symptom treatment ranged from 73% (significant depressive symptoms) to 99% (nausea/vomiting). Symptom severity did not affect the results. Using medical record data, the percentage meeting indicator criteria varied between 4% (significant depressive symptoms) and 23% (pain). For information and care planning, 44% met criteria for discussion about resuscitation and 32% for hospice discussion using survey data. Using medical record data, 11% met criteria for goals-of-care discussion in intensive care and 46% for hospice/pain management/palliative care referral before death. Quality of care for symptoms measured using patient self-report was higher than when including medical record data. Use of patient-reported and medical record data allowed measurement of different perspectives on care planning indicators. Patient-reported data provide a complementary, patient-centered perspective on the quality of supportive oncology care.
    Journal of Oncology Practice 03/2014;
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: Increasing emphasis in performance-based payment, public reporting, and quality improvement (QI) has led to widespread interest in measuring and improving the quality of care. By 2014, hospice programs will be required to report quality data to the federal government or incur financial penalties. With this increased interest in quality reporting comes an opportunity to develop informatics tools to capture data that reflect the complex practices involved in palliative care (PC). Therefore, there is a need to disseminate information on developing tools that facilitate capturing data and fostering improved performance. The Veterans Health Care Administration, a national leader in health information technology (HIT) and PC, established the Quality Improvement Resource Center (QuIRC) to develop innovative HIT tools to standardize and improve PC practices throughout the 153 Department of Veterans Affairs (VA) medical centers nationwide. Objective: The aim of the paper is to describe the development of the Palliative Care-National Clinical Template (PC-NCT) for documenting initial PC consults. Results: Domains of quality of life provided the foundation for this template. Principles of user-centered informatics design guided development activities. A national consensus panel of PC experts prioritized quality indicators as targets for QI. An interdisciplinary team of PC providers identified desired aspects of template functionality. QuIRC balanced PC providers' desired aspects of functionality against the feasibility within the VA HIT system. Formal pilot and usability testing contributed to numerous iterations of the PC-NCT currently piloted in five geographically distributed sites. Conclusion: This paper presents a robust approach to developing an informatics tool for PC practice. Data collected via the PC-NCT will bring variations in current practice into view and assist in directing resources at "important targets" for QI. Although the development of HIT tools to quantify PC practice is complex, there is enormous potential to improve the quality of care for patients and families facing serious illnesses.
    Journal of palliative medicine 02/2014; · 1.84 Impact Factor
  • Journal of Pain and Symptom Management; 02/2014
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: People with chronic heart failure (HF) suffer from numerous symptoms that worsen quality of life. The CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) intervention was designed to improve symptoms and quality of life by integrating palliative and psychosocial care into chronic care. Objective: Our aim was to determine the feasibility and acceptability of CASA and identify necessary improvements. Methods: We conducted a prospective mixed-methods pilot trial. The CASA intervention included (1) nurse phone visits involving structured symptom assessments and guidelines to alleviate breathlessness, fatigue, pain, or depression; (2) structured phone counseling targeting adjustment to illness and depression if present; and (3) weekly team meetings with a palliative care specialist, cardiologist, and primary care physician focused on medical recommendations to primary care providers (PCPs, physician or nurse practioners) to improve symptoms. Study subjects were outpatients with chronic HF from a Veteran's Affairs hospital (n=15) and a university hospital (n=2). Measurements included feasibility (cohort retention rate, medical recommendation implementation rate, missing data, quality of care) and acceptability (an end-of-study semi-structured participant interview). Results: Participants were male with a median age of 63 years. One withdrew early and there were <5% missing data. Overall, 85% of 87 collaborative care team medical recommendations were implemented. All participants who screened positive for depression were either treated for depression or thought to not have a depressive disorder. In the qualitative interviews, patients reported a positive experience and provided several constructive critiques. Conclusions: The CASA intervention was feasible based on participant enrollment, cohort retention, implementation of medical recommendations, minimal missing data, and acceptability. Several intervention changes were made based on participant feedback.
    Journal of palliative medicine 12/2013; · 1.84 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Historically, hospice use by veterans has lagged behind that of non-veterans. Little is known about hospice use by veterans at a population level. To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P = 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P = 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P = 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than non-veterans (one every 5.3 days vs. one every 3.7 days; P = 0.002). Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist.
    Journal of pain and symptom management 11/2013; · 2.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: IMPORTANCE Characterizing the quality of supportive cancer care can guide quality improvement. OBJECTIVE To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans. DESIGN, SETTING, AND PARTICIPANTS Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer. MAIN OUTCOMES AND MEASURES We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ≥30 days following diagnosis with ≥1 Veterans Affairs hospitalization or ≥2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains. RESULTS Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option. CONCLUSIONS AND RELEVANCE These care gaps reflect important targets for improving the patient and family experience of cancer care.
    JAMA Internal Medicine 10/2013; · 13.25 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Physician Orders for Life-Sustaining Treatment (POLST) is a tool to document and ensure continuity of end-of-life treatment decisions across healthcare settings that became a legal document in California in January 2009. Hospitals were surveyed to evaluate factors associated with uptake of this intervention and whether a grassroots community coalition intervention facilitated dissemination. A mail and telephone survey of all acute care hospitals in California was conducted between August 2011 and January 2012, and community coalition reports of interaction with hospitals and hospital characteristics from the California Office of Statewide Planning and Development and Census ZIP Code Tabulation Areas were analyzed. Of 349 hospitals, 286 (81.9%) responded to the survey. Sixty-five percent of hospitals had a policy about POLST, 87% had available blank POLST forms, 84% had educated staff, and 94% reported handling POLST properly in the emergency department and on admission. In multivariable analyses, hospitals in poor areas and for-profit (vs nonprofit) hospitals were less likely to stock blank POLST forms and to have educated staff, and hospitals with community coalition interaction and in wealthier areas were more likely to handle POLST forms correctly. Although POLST is widely used in California, a significant minority of hospitals remain unprepared 3 years after implementation. Efforts to improve implementation should emphasize dissemination in poorer areas and in for-profit hospitals.
    Journal of the American Geriatrics Society 07/2013; · 4.22 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This research explores health care professionals' understanding of the problems that arise in managing a terminal condition impacting the Latino population and conceptualizes the components of patient advocacy that address gaps in end-of-life care for patients and their family members. Limited research exists regarding patient advocacy from the perspectives of health care providers working with vulnerable Latino populations utilizing a public sector health care system. Forty-six semi-structured interviews were conducted with providers from different disciplines including medicine, nursing, social work, and chaplaincy. Although roles and responsibilities vary among health providers, it is imperative that all providers become aware of the need for patient advocacy. Doing so is not only in the best interest of vulnerable Latino populations but also has overarching financial benefits and positive outcomes for patients, administrators, and public health care systems. Social workers are the ideal professionals to assume leadership roles and share their knowledge of how to advocate effectively for the most vulnerable populations.
    Social Work in Health Care 07/2013; 52(6):558-77. · 0.62 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: To examine urology trainees' views about the quality and current practices of end-of-life care and to explore strategies for improving integration and quality of care. METHODS: We conducted semi-structured interviews with 20 trainees from 4 institutions in different regions of the United States. Open-ended questions allowed participants to express themselves independently, and follow-up discussions explored their perception of current end-of-life practices, as well as avenues for future integration and improvement. We analyzed transcripts using a multistage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. RESULTS: Clinicians agreed that their patients do not currently receive ideal care and were interested in joining a team geared towards improving care at the end of life. They expressed a preference for a multidisciplinary team, although the precise role each wanted to play within the team varied. Better identification of depression, pain, and patient-centered goals to allow value-congruent care were high in priorities for improvement. Trainees cited the lack of an educational curriculum on end-of-life care as a barrier to improving care and expressed a desire for formal education on this topic. CONCLUSION: Urology trainees believe that end-of-life care can be improved and are interested in participating as part of a multidisciplinary team to better care for these individuals. There was consensus that end-of-life care should be formally taught to all intern and resident physicians and care at the end of life should be integrated to pursue value-congruent care for each patient.
    Urology 05/2013; · 2.42 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: To evaluate the extent to which physicians engage in recommended elements of advance care planning (ACP) communication during outpatient clinic visits with heart failure (HF) patients. METHODS: We conducted a qualitative content analysis of 71 audio-recorded and transcribed outpatient visits with 52 patients ≥65 years recently hospitalized for HF and their physicians (n=44). RESULTS: We identified 25 instances of ACP-related communication over 15 of the 71 visits: in 17 instances, physicians explained the nature of HF but only once was the life-limiting potential of HF mentioned. Physicians discussed goals of care in 6 instances but elicited their patients' preferences in only 2 of those instances. Finally, physicians encouraged documentation of preferences in 2 instances. CONCLUSIONS: Despite recommendations for early ACP with HF patients, physicians rarely engaged in fundamental elements of ACP discussions during outpatient visits. We suggest a stepwise approach to supporting the process of ACP communication in practice. PRACTICE IMPLICATIONS: Given the importance of ACP in helping patients plan for their future care, outpatient clinicians should be helped to incorporate these discussions in the routine care of their HF patients. Using a simple heuristic might help physicians engage in fundamental elements of ACP during busy outpatient visits.
    Patient Education and Counseling 01/2013; · 2.60 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Research has demonstrated that limited dialogue in end-of-life (EOL) care can negatively impact decision-making and place of death. Furthermore, when vulnerable populations are faced with EOL cancer care, they experience issues resulting from previous gaps in services attributed to sociocultural and economic issues that influence EOL care. These conditions place an additional burden on disadvantaged populations which can cause distress, especially as disparate conditions continue to persist. Little is known about Latinos' psychosocial concerns that lead to distress in EOL care. The objective of this study is to explore Latinas' experiences with life-limiting cancer conditions to identify the EOL care concerns that impact their dying experience. This study used a phenomenological approach to explore the EOL care concerns of 24 Latinas receiving treatment for metastatic cancers in a public sector healthcare system in Los Angeles, California. In-depth interviews were recorded and transcribed, and qualitative analysis was performed using Atlas.ti software.
    OMEGA--Journal of Death and Dying 01/2013; 67(1-2):167-74. · 0.44 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Many patients considered for transplantation die before receiving the organ, underlining the importance of providing high-quality symptomatic relief and communication for all transplant patients. METHODS: To study how consideration of transplantation affects the end-of-life care received by patients, care was evaluated by abstracting medical records for 496 adults who died in one high-volume transplant medical center between April 2005 and April 2006. Sixteen quality indicators from the Assessing Care of Vulnerable Elders set that focused on communication and symptom management were measured to calculate an overall patient-level quality score. We evaluated the predictors of quality of end-of-life care, with the main independent variable being whether the patient was being considered for transplantation. Restricting to patients who died an "expected death," we also evaluated the end-of-life treatments received. RESULTS: Twenty-five percent of decedent patients were considered for transplantation. In adjusted models, patients considered for transplantation received lower-quality end-of-life care, had longer hospital stays before death, and were more likely to receive aggressive life-sustaining treatments. CONCLUSIONS: Care models should incorporate an emphasis on symptom relief and communication along with transplant preparation.
    Transplantation 11/2012; · 3.78 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Implementing Physician Orders for Life Sustaining Treatment (POLST) forms aims to improve communication of life-sustaining treatment preferences across care venues. California enabled this clinical tool in 2009, and a novel intervention of community coalitions was undertaken to advance POLST in localities around the state. Coalitions engaged facilities, including nursing homes (NHs), to foster POLST adoption. Eighteen months after introduction of POLST, we studied POLST implementation in California NHs. METHODS: NHs randomly selected in coalition and non-coalition areas were mailed surveys about POLST preparation and use in 2010. Coalitions identified which NHs they worked with. RESULTS: Of 546 NHs surveyed, 143 (52 %) in coalition areas and 141 (52 %) in non-coalition areas responded. In 82 % of responding NHs, staff received POLST education and 59 % of NHs reported having a formal policy on handling POLST. Two-thirds of NHs had admitted a resident with a POLST, and 15 % of newly admitted residents over the past month had a POLST (range 0-100 %). Eighty-one percent of NHs had completed a POLST with a resident. Fifty-four percent of residents were estimated to have a POLST (range 0-100 %) (coalition area NHs 60 % vs. non- coalition area NHs 48 %, p = 0.02). Within coalition areas, NHs that had worked with coalitions were more likely to have completed a POLST with a resident after admission than NHs that had not worked with coalitions. Few NHs (7 %) reported difficulty following POLST orders, but 38 % noted difficulty involving physicians in POLST completion. CONCLUSION: Less than 2 years after introduction, many California nursing homes report using POLST, although some NHs reported no experience. A novel community coalition intervention facilitated POLST implementation.
    Journal of General Internal Medicine 08/2012; · 3.28 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Aim: To understand provider practices around dyspnea assessment to inform the development of an electronic medical record (EMR)-based dyspnea assessment module in an inpatient palliative care consultation template. Design: Qualitative analysis of palliative care provider interviews. RESULTS: Three themes emerged: (1) integration of patient self-report of breathlessness with a clinical observation of dyspnea; (2) identification of patients for dyspnea assessment based on perceived patient need; and (3) variability in preferences for and use of existing severity scales for dyspnea. CONCLUSIONS: The assessment approaches described by providers underscore the challenge of developing an informatics tool that supports the natural clinical experience and facilitates standardized care. The complexity of the dyspnea assessment process and variation in provider practices necessitate a level of flexibility and choice to be built into a computer-based tool.
    The American journal of hospice & palliative care 06/2012;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Cultural dimensions related to illness are triggered at significant times in an illness trajectory, such as at illness onset or when death approaches. These factors influence views on how illness is understood and managed, which is likely more difficult for minority populations. Although Latinos experience barriers to high-quality health care, late-stage cancer diagnoses, and poor health outcomes, little is known about their experiences with advanced, life-threatening cancers. We examined Latinas' experiences with advanced, metastatic cancers to identify sociocultural beliefs that influenced their care. We interviewed 24 Latinas taking part in a randomized controlled trial focused on improving quality-of-life outcomes for co-occurring cancer and depression and explored their beliefs about the cause, course, and cure of cancer. This study used a phenomenological analytical approach to explore women's lived experiences of having advanced cancer. Themes revealed issues about experiencing advanced cancer that included the following: initial reactions to cancer, disbelief about the lack of pain, economic impact, beliefs about the cause, coping with cancer, beliefs about the cure, and confusion about cancer severity. Sociocultural factors influence misunderstanding and confusion about cancer care but also can be a source of strength. Providers need to become culturally sensitive to the needs of underserved Latinas. Denial or ignorance of these issues can create other problems, such as gaps in patient-centered decision making from diagnosis through the end of life.
    Journal of pain and symptom management 05/2012; 43(6):1013-24. · 2.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. The purpose of this study is to apply novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center. Cancer quality ASSIST is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which we piloted 15 applicable to persons with advanced cancer who died in the hospital setting. We evaluated medical records of all adult terminal hospitalizations with lengths of stay ≥3 days at one university medical center between April 2005 and April 2006. Of 496 decedents, 118 had advanced cancer (mean age 60, 54% male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56% of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23% had a ventilator withdrawn anticipating death. The 118 patients triggered 596 quality indicators of which 476 passed (QI level pass rate 80%, range 50-100%). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26% of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29% of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64 and 69% of cases, respectively. This set of quality indicators can evaluate the quality of supportive and end-of-life care provided to inpatients dying with advanced cancer and identify aspects of care that need improvement.
    Supportive Care in Cancer 04/2012; 20(9):2189-94. · 2.09 Impact Factor
  • Journal of Pain and Symptom Management. 02/2012; 43(2):345.

Publication Stats

1k Citations
385.74 Total Impact Points

Institutions

  • 2013–2014
    • CSU Mentor
      Long Beach, California, United States
  • 2002–2014
    • VA Greater Los Angeles Healthcare System
      Los Angeles, California, United States
  • 2001–2013
    • University of California, Los Angeles
      • • Division of General Internal Medicine and Health Services Research
      • • School of Nursing
      Los Angeles, California, United States
  • 2011
    • Children's Hospital Los Angeles
      Los Angeles, California, United States
    • Cedars-Sinai Medical Center
      • Cedars Sinai Medical Center
      Los Angeles, CA, United States
  • 2009–2011
    • California State University, Long Beach
      • School of Nursing
      Long Beach, CA, United States
    • Kaiser Permanente
      Oakland, California, United States
  • 2005–2011
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2010
    • Johns Hopkins Medicine
      • Department of Health Policy and Management
      Baltimore, MD, United States
  • 2009–2010
    • Mount Sinai School of Medicine
      • Department of Emergency Medicine
      Manhattan, NY, United States
  • 2005–2010
    • RAND Corporation
      Santa Monica, California, United States
  • 2007–2009
    • University of Southern California
      Los Angeles, California, United States
    • Oregon Health and Science University
      • Heart Research Center
      Los Angeles, CA, United States
  • 2008
    • Northwestern University
      • Feinberg School of Medicine
      Evanston, IL, United States
  • 2003–2008
    • U.S. Department of Veterans Affairs
      • General Internal Medicine
      Washington, D. C., DC, United States