Gary E Rosenthal

University of Iowa, Iowa City, Iowa, United States

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Publications (200)1348.75 Total impact

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    ABSTRACT: OBJECTIVE: The experiences of RNs and licensed practical nurses (LPNs) implementing a patientcentered medical home (PCMH) in the Department of Veterans Affairs (VA) primary care clinics were examined to understand model implications for nursing practice and professional identity. BACKGROUND: National implementation of the PCMHmodel, called patient-aligned care teams (PACTs) inVA, emphasizes areas of nursing expertise, yet little is known about the effect of medical homes on the day-to-day work of nurses. METHODS: As part of a formative evaluation to identify barriers and facilitators to PACT implementation, we interviewed 18 nurses implementing PACT. RESULTS: Challenges to nurse's organizational and professional roleswere experienced differently by RNs and LPNs in the following areas: (1) diversified modes of care and expanded clinical duties, (2) division of labor among PACT nurses, and (3) interprofessional status in the team. CONCLUSIONS: Healthcare managers implementing PCMH should consider its inherent cultural and practice transformations.
    JONA The Journal of Nursing Administration 11/2015; 45(11):569-574. DOI:10.1097/NNA.0000000000000265 · 1.27 Impact Factor
  • Ashish Malhorta · Mary Vaughan-Sarrazin · Gary E Rosenthal ·
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    ABSTRACT: To examine the receipt of colonoscopy through the Veterans Health Administration (VA) or through Medicare by older veterans who are dually enrolled. Retrospective cohort study. The VA Outpatient Care Files and Medicare Enrollment Files were used to identify 1,060,523 patients 65 years and older in 15 of the 22 Veterans Integrated Service Networks nationally, who had 2 or more VA primary care visits in 2009 and who were simultaneously enrolled in Medicare. VA and Medicare files were used to identify the receipt of an outpatient colonoscopy. Patients were categorized as receiving care in community-based outpatient clinics (CBOCs) (n = 601,337; 57%) or VA medical centers (n = 459,186; 43%) based on where most patient-centered encounters occurred. Analyses used multinomial logistic regression to identify patient characteristics related to the odds of receiving a colonoscopy at the VA or through Medicare. Patients had a mean age of 76.9 (SD = 7.0) years; 98% were male, 89% were white, and 21% resided in a rural location. Overall, 100,060 (9.4%) patients underwent outpatient colonoscopy either through the VA (n = 33,600; 35.5%) or Medicare providers (n = 65,716; 65.5%). The adjusted odds of receiving a colonoscopy from Medicare providers were higher (P < .001) for patients who were male, white, receiving primary care at CBOCs, and for residents of an urban location. The receipt of colonoscopy through the VA decreased dramatically by age; for example, the odds of colonoscopy by the VA in patients aged > 85 years and 80 to 84 years, relative to patients aged 65 to 69 years, were 0.26 and 0.13, respectively. In contrast, the receipt of colonoscopy through Medicare did not decline as markedly with age. In a national analysis of the receipt of an outpatient colonoscopy by older veterans, more veterans received their colonoscopies through CMS than through the VA. The use of colonoscopy within the VA was found to be more concordant with age-related practice guidelines.
    The American journal of managed care 08/2015; 21(4):e264-70. · 2.26 Impact Factor
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    ABSTRACT: Importance: Percutaneous ventricular assist devices (PVADs) provide robust hemodynamic support compared with intra-aortic balloon pumps (IABPs), but clinical use patterns are unknown. Objective: To examine contemporary patterns in PVAD use in the United States and compare them with use of IABPs. Design, Setting, and Participants: Retrospective study of adults older than 18 years who received a PVAD or IABP while hospitalized in the United States (2007-2012). Main Outcomes and Measures: Temporal trends in utilization, patient and hospital characteristics, in-hospital mortality, and cost of PVAD use compared with IABP. Results: During 2007 through 2012, utilization of PVADs increased 30-fold (4.6 per million discharges in 2007 to 138 per million discharges in 2012; P for trend < .001) while utilization of IABPs decreased from 1738 per million discharges in 2008 to 1608 per million discharges in 2012 (P for trend = .02). In 2007, an estimated 72 hospitals used PVADs, increasing to 477 in 2011 (P for trend < .001). The number of hospitals with an annual volume of 10 or more PVAD procedures per year increased from 0 in 2007 to 102 in 2011 (21.4% of PVAD-using hospitals; P for trend < .001). Among PVAD recipients, 67.3% had a diagnosis of cardiogenic shock or acute myocardial infarction (AMI). There was a temporal increase in the use of PVADs in older patients and patients with AMI, hypertension, diabetes mellitus, and chronic kidney disease (P for trend < .001 for all). Overall, mortality in PVAD recipients was 28.8%, and mean (SE) hospitalization cost was $85 580 ($4165); both were significantly higher in PVAD recipients with cardiogenic shock (mortality, 47.5%; mean [SE] cost, $113 695 [$6260]; P < .001 for both). The PVAD recipients were less likely than IABP recipients to have cardiogenic shock (34.3% vs 41.2%; P = .001), AMI (48.0% vs 68.6%; P < .001), and undergo coronary artery bypass graft surgery (6.2% vs 43.2%; P < .001), but more likely to undergo percutaneous coronary intervention (70.9% vs 40.4%; P < .001). In propensity-matched analysis, PVADs were associated with higher mortality compared with IABP (odds ratio, 1.23 [95% CI, 1.06-1.43]; P = .007). Conclusions and Relevance: There has been a substantial increase in the use of PVADs in recent years with an accompanying decrease in the use of IABPs. Given the high mortality, associated cost, and uncertain evidence for a clear benefit, randomized clinical trials are needed to determine whether use of PVADs leads to improved patient outcomes.
    JAMA Internal Medicine 06/2015; 175(6):941-50. DOI:10.1001/jamainternmed.2014.7856 · 13.12 Impact Factor
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    Carter BL · VanderWeg MW · Parker CP · Goedken CC · Richardson KK · Rosenthal GE ·

    Journal of Clinical Hypertension 06/2015; · 2.85 Impact Factor
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    ABSTRACT: Clinical pharmacists are utilized in Veterans Health Administration (VHA) facilities to assist with management of patients with chronic conditions including hypertension. The goal of this study was to examine blood pressure (BP) control after discontinuation of an intensive pharmacist-managed intervention. The study was conducted at a single Midwest VHA medical center and two affiliated community-based outpatient clinics. Patients with uncontrolled BP received an intensive pharmacist intervention for the first 6 months. Patients were then stratified based on whether their BP was controlled or not and were randomized to either continue the intervention for another 24 months (30 month total time period) or the intervention was discontinued following one-time receipt of educational materials. Mean systolic and diastolic BPs were reduced (P<.001) in diabetic patients (8.0±14.4 mm Hg and 4.0±9.1 mm Hg, respectively) and in nondiabetic patients (14.0±16.4 mm Hg and 5.0±10.0 mm Hg, respectively) following the 6-month intervention, with 54% of the total sample achieving BP control. BP control and the reduction in mean BP was maintained to a similar degree in both study groups at 12, 18, 24, and 30 months. There were no significant differences in BP at any of the follow-up periods in patients who did and did not receive the continued pharmacist intervention. This study found that BP control was maintained for at least 24 months following discontinuation of an intensive pharmacist intervention. These findings were seen in both the group that had a continued pharmacist intervention and in the group that had a one-time educational session when the intervention was discontinued. This study suggests that once BP control is achieved following a pharmacist intervention, patients can be referred back to their primary care provider for continued follow-up. ©2015 Wiley Periodicals, Inc.
    Journal of Clinical Hypertension 05/2015; 17(9). DOI:10.1111/jch.12577 · 2.85 Impact Factor
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    ABSTRACT: Implementation of a patient centered medical home challenges primary care providers to change their scheduling practices to enhance patient access to care as well as to learn how to use performance metrics as part of a self-reflective practice redesign culture. As medical homes become more commonplace, health care administrators and primary care providers alike are eager to identify barriers to implementation. The objective of this study was to identify non-technological barriers to medical home implementation from the perspective of primary care providers. We conducted qualitative interviews with providers implementing the medical home model in Department of Veterans Affairs clinics-the most comprehensive rollout to date. Primary care providers reported favorable attitudes towards the model but discussed the importance of data infrastructure for practice redesign and panel management. Respondents emphasized the need for administrative leadership to support practice redesign by facilitating time for panel management and recognizing providers who utilize non-face-to-face ways of delivering clinical care. Health care systems considering adoption of the medical home model should ensure that they support both technological capacities and vertically aligned expectations for provider performance. Published by Elsevier Inc.
    Healthcare 08/2014; 2(4). DOI:10.1016/j.hjdsi.2014.07.004
  • Michael E Ohl · Gary E Rosenthal ·

    JAMA The Journal of the American Medical Association 07/2014; 312(3):235-6. DOI:10.1001/jama.2014.7690 · 35.29 Impact Factor
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    ABSTRACT: Patient-centered medical homes (PCMHs) are a newer paradigm of health care service delivery. Team-based care that includes pharmacists has been implemented in several countries. Subsequently studies have successfully identified challenges and barriers with team-based care. Research on pharmacists' integration into PCMH is warranted to help bridge knowledge from earlier studies exploring team-based care. In 2010, the Department of Veteran Affairs (VA) began a national PCMH implementation, operationalized as "Patient-Aligned Care Teams" (PACTs). The VA's national PACT implementation presents an opportunity to describe other persistent barriers to effective coordination between primary care and pharmacy providers.
    Research in Social and Administrative Pharmacy 05/2014; 11(1). DOI:10.1016/j.sapharm.2014.05.005 · 2.35 Impact Factor
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    ABSTRACT: The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.
    Journal of General Internal Medicine 04/2014; 29(10). DOI:10.1007/s11606-014-2848-3 · 3.42 Impact Factor
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    ABSTRACT: This paper examines blood pressure (BP) control after 6 months of an intensive pharmacist-managed intervention in a mixed-methods randomized controlled trial conducted at the Iowa City Veteran Affairs Health Care System and two community-based outreach clinics. Patients received the pharmacist intervention for the first 6 months. The study coordinator conducted a summative evaluation with 37 patients 18 to 24 months following the initial 6-month intervention period. BP was significantly reduced in diabetic patients following an intensive pharmacist intervention (-8.0/-4.0±14.4/9.1 mm Hg systolic/diastolic, P<.001 and P=.001, respectively). BP was reduced even more in nondiabetic patients (-14.0/-5.0±1.9/10.0 mm Hg, P<.001). Medication adherence significantly improved from baseline to 6 months (P=.017). BPs were significantly lower at 6 months following an intensive pharmacist intervention. Patients also expressed a high level of satisfaction with and preference for co-management of their hypertension, as well as other chronic diseases.
    Journal of Clinical Hypertension 02/2014; 16(2):133-40. DOI:10.1111/jch.12250 · 2.85 Impact Factor
  • Janel Hanmer · Xin Lu · Gary E. Rosenthal · Peter Cram ·

    Annals of internal medicine 01/2014; 160(2):81-90. DOI:10.7326/M12-1977 · 17.81 Impact Factor
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    Janel Hanmer · Xin Lu · Gary E Rosenthal · Peter Cram ·
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    ABSTRACT: There is little objective evidence to support concerns that patients are transferred between hospitals based on insurance status. To examine the relationship between patients' insurance coverage and interhospital transfer. Data analyzed from the 2010 Nationwide Inpatient Sample. All patients aged 18 to 64 years discharged alive from U.S. acute care hospitals with 1 of 5 common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, and skin or subcutaneous infection). For each diagnosis, the proportion of hospitalized patients who were transferred to another acute care hospital based on insurance coverage (private, Medicare, Medicaid, or uninsured) was compared. Logistic regression was used to estimate the odds of transfer for uninsured patients (reference category, privately insured) while patient- and hospital-level factors were adjusted for. All analyses incorporated sampling and poststratification weights. Among 315 748 patients discharged from 1051 hospitals with any of the 5 diagnoses, the percentage of patients transferred to another acute care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses, uninsured patients were significantly less likely to be transferred for 3 diagnoses (P 0.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for 4 diagnoses: biliary tract disease (odds ratio, 0.73 [95% CI, 0.55 to 0.96]), chest pain (odds ratio, 0.63 [CI, 0.44 to 0.89]), septicemia (odds ratio, 0.76 [CI, 0.64 to 0.91]), and skin infections (odds ratio, 0.64 [CI, 0.46 to 0.89]). Women were significantly less likely to be transferred than men for all diagnoses. This analysis relied on administrative data and lacked clinical detail. Uninsured patients (and women) were significantly less likely to undergo interhospital transfer. Differences in transfer rates may contribute to health care disparities. National Institutes of Health.
    Annals of internal medicine 01/2014; 160(2):81-90. · 17.81 Impact Factor
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    ABSTRACT: Background Patient-centered medical homes (PCMHs) are a newer paradigm of health care service delivery. Team-based care that includes pharmacists has been implemented in several countries. Subsequently studies have successfully identified challenges and barriers with team-based care. Research on pharmacists’ integration into PCMH is warranted to help bridge knowledge from earlier studies exploring team-based care. In 2010, the Department of Veteran Affairs (VA) began a national PCMH implementation, operationalized as “Patient-Aligned Care Teams” (PACTs). The VA’s national PACT implementation presents an opportunity to describe other persistent barriers to effective coordination between primary care and pharmacy providers. Objective To identify perceived barriers and facilitators to pharmacist integration into VA PACTs from the perspective of non-pharmacist team members. Methods Semi-structured interviews were conducted as part of a formative evaluation of PCMH implementation. Participants were from VA medical centers and community-based outpatient clinics in the Midwestern United States and included physicians, nurses, associated health care professionals, and health system administrators. Results In working toward pharmacy service integration, role clarity and work activities were influenced by team member attitudes towards and previous experiences with pharmacists. Interviewees reported that coordination with pharmacists was hindered if communication placed extra burdens on other team members. Interviewees reported collaboration was easier when pharmacists were on-site, but that technology helped facilitate off-site access to pharmacy services. Finally, some team members characterized pharmacist integration as essential while others failed to integrate pharmacists at all. Conclusion Non-pharmacist members of PACT teams reported some reluctance in pharmacists’ integration. They attributed this reluctance to knowledge deficits, limited participation in PACT training by pharmacists, an imbalance in effort expended for pharmacists’ integration, and coordination or communication challenges. While there may be unique opportunities for pharmacists to improve patient care through participation in PCMHs, work remains to improve other health professionals’ knowledge of and attitudes towards pharmacists’ roles on health care teams.
    Research in Social and Administrative Pharmacy 01/2014; · 2.35 Impact Factor
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    ABSTRACT: Blood pressure exhibits circadian variability, and nighttime blood pressure is one of the best predictors of cardiovascular (CV) events. Adults with hypertension who lack a nighttime dipping pattern are at particularly high risk. Several studies have found that bedtime dosing of antihypertensive agents reduces sleep blood pressure and improves the dipping pattern in nondippers. One small study and 2 substudies of diabetes and chronic kidney disease suggest that bedtime dosing of ≥1 antihypertensives significantly reduced CV events. A Cochrane review of 5 studies found no difference in adverse events between morning and evening dosing. However, several evaluations in ophthalmology have found that nocturnal arterial hypotension precipitated ocular vascular disorders such as ischemic optic neuropathy. Some authors have suggested that additional studies of nighttime dosing of antihypertensive agents that evaluate CV events need to be conducted. The authors describe a randomized controlled pragmatic trial that is being planned at the University of Iowa and Duke University. Patients with hypertension and other comorbid conditions will be randomized to either continue morning dosing of all antihypertensive agents or to switch their nondiuretic medications to bedtime dosing. Patients will be followed for 36 to 42 months. This study will determine whether nighttime dosing reduces CV risk when compared with traditional morning dosing of antihypertensive agents.
    Journal of Clinical Hypertension 12/2013; 16(2). DOI:10.1111/jch.12238 · 2.85 Impact Factor
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    Gary E Rosenthal · Mary Vaughan-Sarrazin ·
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    ABSTRACT: Each July, teaching hospitals experience an influx of new residents and fellows who have recently graduated from medical school or completed residency training programs. During this period, teaching hospitals also assign new positions of responsibility to existing residents and fellows. Medical education is a core mission of teaching hospitals, and in these hospitals, interns, residents, and fellows play major roles in patient care. This recurrent cycle in which care is delivered by less experienced physicians in the initial month of the academic year has led to the often expressed conventional wisdom of "not to get sick in July."(1) In addition to the lore surrounding July admissions to teaching hospitals, prior studies have shown that physician experience is an important determinant of outcomes for a wide range of medical conditions and procedures. (2-5) Moreover, literature from economics and other fields has shown that employee turnover can adversely affect organizational productivity.(6,7) Given that teaching hospitals face both inexperienced physicians as well as high turnover early in the academic year, it is reasonable to be concerned about the potential for lower quality care around that time.
    Circulation 10/2013; 128(25). DOI:10.1161/CIRCULATIONAHA.113.006758 · 14.43 Impact Factor
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    Jasvinder A Singh · Xin Lu · Gary E Rosenthal · Said Ibrahim · Peter Cram ·
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    ABSTRACT: To examine whether racial disparities in usage and outcomes of total knee and total hip arthroplasty (TKA and THA) have declined over time. We used data from the US Medicare Program (MedPAR data) for years 1991-2008 to identify four separate cohorts of patients (primary TKA, revision TKA, primary THA, revision THA). For each cohort, we calculated standardised arthroplasty usage rates for Caucasian and African-American Medicare beneficiaries for each calendar year, and examined changes in disparities over time. We examined unadjusted and adjusted outcomes (30-day readmission rate, discharge disposition etc.) for Caucasians and African-Americans, and whether disparities decreased over time. In 1991, the use of primary TKA was 36% lower for African-Americans compared with Caucasians (20.6 per 10 000 for African-Americans; 32.1 per 10 000 for Caucasians; p<0.0001); in 2008, usage of primary TKA was 40% lower for African-Americans (41.5 per 10 000 for African-Americans; 68.8 per 10 000 for Caucasians; p<0.0001) with similar findings for the other cohorts. Black-White disparities in 30-day hospital readmission increased significantly from 1991-2008 among three patient cohorts. For example in 1991 30-day readmission rates for African-Americans receiving primary TKA were 6% higher than for Caucasians; by 2008 readmission rates for African-Americans were 24% higher (p<0.05 for change in disparity). Similarly, black-white disparities in the proportion of patients discharged to home after surgery increased across the study period for all cohorts (p<0.05). In an 18-year analysis of US Medicare data, we found little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.
    Annals of the rheumatic diseases 09/2013; 73(12). DOI:10.1136/annrheumdis-2013-203494 · 10.38 Impact Factor
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    ABSTRACT: To compare colorectal cancer screening rates in veterans receiving primary care (PC) in Veterans Administration (VA) community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs). The VA Outpatient Care Files were used to identify 2 837 770 patients ≥50 years with ≥2 PC visits in 2010. Veterans undergoing screening/surveillance colonoscopy, sigmoidoscopy, fecal-occult-blood testing (FOBT), and double-contrast barium enema (DCBE) were identified from ICD-9-CM/CPT codes. Patients were categorized as VAMC (n = 1 403 273; 49.5%) or CBOC (1 434 497; 50.5%) based on where majority of PC encounters occurred and as high risk (n = 284 090) or average risk (n = 2 553 680) based on colorectal cancer risk factors and validated ICD-9-CM-based algorithms. CBOC patients were older than VAMC (mean ages 69.3 vs 67.4 years; P < .001), more likely (P < .001) to be male (96.5% vs 95.1%), and white (67.8% vs 64.2%), but less likely to be high-risk (9.4% vs 10.5%; P < .001). Rates of colonoscopy, sigmoidoscopy, and DCBE were all lower in CBOC (P < .001). Among high-risk veterans, rates in CBOC and VAMC, respectively, were 27.4% versus 36.8% for colonoscopy, 1.3% versus 0.8% for sigmoidoscopy, and 0.8% versus 0.5% for DCBE. Among average-risk veterans, these rates were 1.3% versus 1.9%, 0.2% versus 0.1%, and 0.2% versus 0.1%, respectively. The differences remained after adjusting for age/comorbidity. The adjusted odds of colonoscopy for CBOC were 0.73 (95% confidence interval = 0.64-0.82) for average risk and 0.76 (95% confidence interval = 0.67-0.87) for high risk. In contrast, the use of FOBT was relatively similar in CBOCs and VAMCs among both high risk (11.1% vs 11.2%) and average risk (14.3% vs 14.1%). Screening rates were similar between those younger than 65 years and older than 65 years. Veterans receiving PC in CBOCs are less likely to receive screening colonoscopy, sigmoidoscopy, and DCBE than VAMC according to VA records. The lower use in CBOC was not offset by higher use of FOBT, including the degree to which CBOC patients may be more reliant to use non-VA services. The clinical appropriateness of these differences merits further examination.
    Journal of primary care & community health 07/2013; 5(1). DOI:10.1177/2150131913494842
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    Ashish Malhotra · Mary Vaughan-Sarrazin · Gary Rosenthal ·

    Gastrointestinal Endoscopy 05/2013; 77(5):AB226. DOI:10.1016/j.gie.2013.03.546 · 5.37 Impact Factor
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    ABSTRACT: Purpose:To examine the relationship between posttraumatic stress disorder (PTSD) and computed tomography (CT) utilization and to determine whether there were patterns of comorbid illness that could explain the relationship.Materials and Methods:The study was approved by the University of Iowa Institutional Review Board and the Iowa City Veterans Affairs Medical Center Research and Development Committee. By using a retrospective cohort design, a national sample of new veteran enrollees aged 18-35 years was studied. Associations were examined between the presence of PTSD, receipt of at least one and multiple CT scans, comorbid medical conditions (eg, abdominal pain, headaches), and measures of health care utilization (eg, primary care, emergency room, and mental health visits) and the daily probability of the receipt of at least one CT scan before and after a diagnosis of PTSD. Analyses included sequential multivariable generalized linear mixed models to examine the independent relationship between PTSD and CT scan utilization.Results:Among the full cohort, 13.0% (10 018 of 76 812) received at least one CT scan. PTSD was identified in 21.1% (16 182 of 76 812) of the cohort, and 22.9% (3711 of 16 182) of veterans with PTSD received at least one CT scan as compared with 10.4% (6307 of 60 630) of veterans without PTSD (P < .0001). In sequential modeling, comorbid factors explaining the relationship between CT scans and PTSD were traumatic brain injury (odds ratio, 3.54; P < .0001), abdominal pain (odds ratio, 4.01; P < .0001), and headaches (odds ratio, 3.07; P < .0001). Associations were also strong for high levels of emergency room (odds ratio, 2.73; P < .0001) and primary care (odds ratio, 2.38; P < .0001) utilization. The daily chance of receiving a CT scan was seven times higher prior to the recognition of PTSD (daily chance, 0.007 before vs 0.001 after; P < .0001).Conclusion:Young veterans with PTSD are receiving more CT scans compared with those without PTSD; the daily probability of receiving CT scans is higher prior to recognition of PTSD.© RSNA, 2013Supplemental material:
    Radiology 01/2013; 267(2). DOI:10.1148/radiol.13121593 · 6.87 Impact Factor
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    ABSTRACT: Chinese translation Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. Observational study from 1997 to 2010. All 129 acute care Veterans Affairs hospitals in the United States. 4 124 907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.
    Annals of internal medicine 12/2012; 157(12):837-45. DOI:10.7326/0003-4819-157-12-201212180-00003 · 17.81 Impact Factor

Publication Stats

6k Citations
1,348.75 Total Impact Points


  • 1998-2015
    • University of Iowa
      • • Institute for Clinical and Translational Science
      • • Department of Internal Medicine
      • • Carver College of Medicine
      • • Department of Health Management and Policy
      Iowa City, Iowa, United States
  • 2009
    • Texas A&M University
      College Station, Texas, United States
  • 2006
    • Oregon Health and Science University
      • Division of Cardiothoracic Surgery
      Portland, Oregon, United States
    • University of California, San Francisco
      • Department of Medicine
      San Francisco, California, United States
  • 1995-2002
    • Case Western Reserve University
      • School of Medicine
      Cleveland, Ohio, United States
    • United States Department of Veterans Affairs
      Бедфорд, Massachusetts, United States
  • 1993-2001
    • Louis Stokes Cleveland VA Medical Center
      Cleveland, Ohio, United States
  • 1999
    • Baylor College of Medicine
      Houston, Texas, United States
  • 1990-1998
    • Case Western Reserve University School of Medicine
      • Department of Medicine
      Cleveland, Ohio, United States
  • 1991-1996
    • Cleveland State University
      Cleveland, Ohio, United States
  • 1992
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States