David Casarett

Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (158)1055.07 Total impact

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    ABSTRACT: Abstract Background: Most pediatric hospice patients receive services from agencies typically oriented to adults. Information regarding how pediatric hospice patients differ from adult hospice patients is lacking. Objective: We aim to assess differences between pediatric and adult hospice patients regarding patient characteristics and outcomes. Methods: We compiled a retrospective inception cohort of patients enrolled at nine hospices in the CHOICE network (Coalition of Hospices Organized to Investigate Comparative Effectiveness) between August 1, 2008 and June 30, 2012. Measurements included patient characteristics and outcomes, including discharge from hospice and site of death. Results: Among 126,620 hospice patients, 986 (0.8%) were 18 years of age or younger. Pediatric patients were less likely to have an admitting diagnosis of cancer (odds ratio [OR] 0.62; 95% confidence interval [CI]: 0.54-0.72). Although children were less likely to use oxygen at enrollment (OR 0.31; 95% CI: 0.26-0.37), they were more likely to have an enteral feeding tube (OR 4.04; 95% CI: 3.49-4.67). Pediatric patients were half as likely as adults to have a do-not-resuscitate order (DNR) order upon hospice enrollment (OR 0.52; 95% CI: 0.46-0.59). The average hospice length of stay for pediatric patients was longer than that of adults (103 days versus 66 days, p<0.001). Children were more likely to leave hospice care (OR 2.59; 95% CI: 2.00-3.34), but among patients who died while enrolled in hospice, pediatric patients were more likely to die at home (OR 3.25; 95% CI: 2.27-3.88). Conclusions: Pediatric hospice patients differ from adult patients in their broader range of underlying diagnoses and their use of hospice services.
    Journal of palliative medicine. 11/2014;
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    ABSTRACT: Growth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home.
    BMJ supportive & palliative care. 11/2014;
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    ABSTRACT: To define patient characteristics associated with hospice enrollment in the last 3 days of life, and to describe adjusted proportions of patients with late referrals among patient subgroups that could be considered patient-mix adjustment variables for this quality measure.
    Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 08/2014;
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    ABSTRACT: Abstract Objective: To determine whether it is possible to predict, at the time of hospice enrollment, which patients will die within 6 months. Design: Electronic health record-based retrospective cohort study. Setting: Patients admitted to 10 hospices in the CHOICE network (Coalition of Hospices Organized to Investigate Comparative Effectiveness). Participants: Hospice patients. Main outcome measures: Mortality at 6 months following hospice admission. Results: Among 126,620 patients admitted to 10 hospices, 118,532 (93.6%) died within 6 months. In a multivariable logistic regression model, five characteristics were independent predictors of 6-month mortality. For instance, patients younger than 65 years were less likely to die within 6 months (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.45-0.91; p=0.014). Conversely, male patients were more likely to die within 6 months (OR 1.47; 95% CI 1.05-2.02; p=;0.036). After adjusting for other variables in this model, there were several subgroups with a low probability of 6-month probability (e.g., stroke and Palliative Performance Scale [PPS] score=50; adjusted probability of 6-month mortality=39.4%; 95% CI: 13.9%-72.5%). However, 95% confidence intervals of these 6-month mortality predictions extended above 50%. Conclusions: Hospices might use several variables to identify patients with a relatively low risk for 6-month mortality and who therefore may become ineligible to continue hospice services if they fail to show significant disease progression.
    Journal of palliative medicine. 06/2014;
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    ABSTRACT: To describe individuals with advance directives at the time of hospice enrollment and to determine whether they have patterns of care and outcomes that are different from those of individuals without advance directives.
    Journal of the American Geriatrics Society 05/2014; · 4.22 Impact Factor
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    ABSTRACT: Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care. To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement. We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care VA facilities between 2010-2011. Outcomes included: 1) palliative care consult; 2) chaplain visit; and 3) death in an inpatient hospice/palliative care unit. We also assessed DNR orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice/palliative care unit death, and DNR, we additionally adjusted for palliative care consults. Mean (SD) age was 74(± 12) years, 98% were men, and 19% were non-White. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative consult, AOR 4.31 (95% CI 3.90-4.76), a chaplain visit, AOR 1.18 (95% CI 1.07-1.31), and a DNR order, AOR 4.59 (95% CI 4.08-5.16), but not more likely to die in a hospice/palliative care unit. Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit, and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.
    Journal of pain and symptom management 05/2014; · 2.42 Impact Factor
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    ABSTRACT: Abstract Background: All hospices were required by the Centers for Medicare and Medicaid Services (CMS) to collect the "Comfortable Dying" measure in 2012 (National Quality Forum measure #0209). However, it is not known how scores on this measure are affected by patient characteristics. It is important to identify these characteristics so that a hospice's case mix can be taken into account when interpreting its scores. Objective: Our aim was to describe the implementation of the NQF #0209 measure in 10 hospices and to identify patient characteristics associated with scores. Methods: We conducted an electronic health record (EHR)-based retrospective cohort study of patients in 10 hospices in the United States. The main outcome measure was the proportion of patients with pain that made them uncomfortable whose pain was controlled within 48 hours. Results: A total of 4157 patients were eligible for an initial pain assessment. Of those who reported pain (n=1992), 1152 (58%) reported having their pain controlled on the follow-up assessment. In a multivariable regression model, clustered by hospice, six variables were independently associated with pain control. These included age (adjusted odds ratio [OR] 1.02; 95% confidence interval [CI] 1.02-1.03, p=0.003), a cancer diagnosis (OR 1.37; 95% CI 1.20-1.53, p=0.008), initial care in an inpatient unit (OR 1.28; 95% CI 1.08-1.47, p=0.031), presence of a Foley catheter (OR 1.40; 95% CI 1.15-1.59, p=0.038), use of opioid medication (OR 1.34; 95% CI 1.03-1.74, p=0.027), and higher Palliative Performance Scale (PPS) score (OR 1.02; 95% CI 1.01-1.03, p<0.001). Presence of a Stage 2 pressure ulcer was independently associated with worse pain control (OR 0.63; 95% CI 0.31-0.96, p=0.012). Conclusions: Several patient characteristics are associated with #0209 pain scores. As hospices are increasingly required to report quality measures, it will be essential to understand how their scores are affected by case mix.
    Journal of palliative medicine 04/2014; · 1.84 Impact Factor
  • Journal of Pain and Symptom Management 02/2014; 47(2):381. · 2.60 Impact Factor
  • Sally E Kraynik, David J Casarett, Amy M Corcoran
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    ABSTRACT: Dying patients whose implantable cardioverter defibrillators (ICDs) continue to deliver shocks may experience significant pain, and the National Quality Forum has endorsed routine deactivation of ICDs when patients near the end of life. The overarching goal of this quality improvement project was to increase rates of ICD deactivation among hospice patients. ICD deactivation rates pre- vs. post-intervention; and clinicians' knowledge and confidence regarding ICD management. A multifaceted intervention included clinical tools, education, and standardized documentation templates in the electronic medical record. The proportion of patients whose ICD was deactivated increased after the intervention (pre- vs. post-intervention: 39/68, 57% vs. 47/56, 84%; odds ratio 3.88; 95% confidence interval 1.54-10.37; P = 0.001). Clinicians' knowledge and confidence regarding ICD management improved (pre- vs. post-intervention median questionnaire scores: 5 vs. 9 on a scale of 0 to 10; Wilcoxon signed-rank test Z = -5.01; P < 0.001). A multifaceted intervention can increase rates of ICD deactivation among patients near the end of life.
    Journal of pain and symptom management 01/2014; · 2.42 Impact Factor
  • Thomas W. LeBlanc, Amy P. Abernethy, David J. Casarett
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    ABSTRACT: Context. Although much is known about solid tumor patients who utilize hospice, the hematologic malignancies hospice population is inadequately described. Objectives To compare the characteristics and outcomes of hospice patients with hematologic malignancies to those with solid tumors. Methods We extracted electronic patient data (2008-2012) from a large hospice network (CHOICE), and used bivariate analyses to describe between-group differences. Results In total, 48,147 patients with cancer were admitted during the study period; 3518 (7.3%) had a hematologic malignancy. These patients had significantly worse Palliative Performance Scale scores (32% vs. 24% were below 40; P<0.001) and shorter lengths of stay (median 11 days vs. 19; P<0.001). They were more likely to die within 24 hours of hospice enrollment (10.9% vs. 6.8%; odds ratio [OR] 1.66, 95% confidence interval [CI] 1.49, 1.86, P<0.001) or within seven days (36% vs. 25.1%; OR 1.68, 95% CI 1.56, 1.81, P<0.001), and were more likely to receive hospice services in an inpatient or nursing home setting (OR 1.34, 95% CI 1.16, 1.56, and OR 1.54, 95% CI 1.39, 1.72, both P<0.001). Among hematologic malignancy patients, those with leukemia had the shortest survival (hazard ratio 1.23, 95% CI 1.13, 1.34, P<0.001), and 40.3% used hospice for less than seven days (OR 1.31, 95% CI 1.11, 1.56, P=0.002). Conclusion Hospice patients with hematologic malignancies are more seriously ill at time of admission, with worse functional status and shorter length of stay than other cancer patients. Differences in outcomes suggest the need for targeted interventions to optimize hospice services for the hematologic malignancies population, especially those with leukemia.
    Journal of Pain and Symptom Management. 01/2014;
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    ABSTRACT: Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the United States shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), “here is what we do,” and increase the focus on “this is how well we do it” and “let’s see how we can do it better.” It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.
    Journal of Pain and Symptom Management. 01/2014;
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    ABSTRACT: Context Nursing homes (NHs) are increasingly the site of hospice care. High quality of care is dependent on successful NH-hospice collaboration. Objectives To examine bereaved family members’ perceptions of NH-hospice collaborations in terms of what they believe went well or could have been improved. Methods Focus groups were conducted with bereaved family members from five diverse geographic regions, and included participants from inner-city and rural settings, with over-sampling of blacks. Results Twenty-eight participants (14.8% African American, mean age 61.4 years) identified three major aspects of collaboration as important to care delivery. First, the majority (67.9%) voiced concerns with knowing who (NH or hospice) is responsible for which aspects of patient care. Second, nearly half (42.9%) stated concern about information coordination between the NH and hospice. Finally, 67.9% of participants mentioned the need for hospice to advocate for high-quality care rather than their having to directly do so on behalf of their family members. Conclusion The important concerns raised by bereaved family members about NH-hospice collaboration have been incorporated into the revised Family Evaluation of Hospice Care (FEHC), a post-death survey used to evaluate quality of hospice care.
    Journal of pain and symptom management 01/2014; · 2.42 Impact Factor
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    ABSTRACT: Acupuncture is a complementary and alternative medicine (CAM) modality that shows promise as a component of supportive breast cancer care. Lack of robust recruitment for clinical trial entry has limited the evidence base for acupuncture as a treatment modality among breast cancer survivors. The objective of this study is to identify key decision-making factors among breast cancer survivors considering entry into an acupuncture clinical trial for treatment of symptoms. Semistructured interviews were conducted among African-American (n = 12) and Caucasian (n = 13) breast cancer survivors. Verbatim transcripts were made and analyzed by two or more independent coders using NVivo software. Major recurring themes were identified and a theoretical framework developed. Six themes emerged reflecting key attributes of the decision to enter a clinical trial: (1) symptom appraisal, (2) practical barriers (e.g., distance and travel), (3) beliefs about the interventions (e.g., fear of needles and dislike of medications), (4) comfort with elements of clinical trial design (e.g., randomization, the nature of the control intervention, and blinding), (5) trust, and (6) altruism. African-American and Caucasian women weighed similar attributes but differed in the information sources sought regarding clinical trial entry and in concerns regarding the use of a placebo in a clinical trial. Our findings contribute to the development of a theoretical model of decision making for breast cancer survivors considering participation in a CAM clinical trial. Insights regarding the decision making process can inform interventions to support informed decision making and robust recruitment to CAM trials among cancer survivors.
    Supportive Care in Cancer 12/2013; · 2.09 Impact Factor
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    ABSTRACT: Abstract Background: Although hospices need to be able to anticipate patient acuity, there are currently no published models that predict the frequency of visits that a new hospice patient is likely to receive. Objectives: To identify patient characteristics that are associated with the frequency of health care provider visits in the first 8 days of hospice care. Methods: An electronic health record (EHR)-based retrospective cohort study was conducted in seven hospice programs in the United States. Participants were 35,232 patients who were admitted between October 1, 2008 and May 31, 2011 and received hospice care at home on the day of enrollment. The main outcome measure was the average number of visits per day by nurses, social workers, chaplains, and home health aides in the first 8 days of home hospice care (day of admission plus up to 7 subsequent days). Results: In a mixed effects regression model, 14 independent predictors of visit frequency were identified. For instance, several demographic characteristics were associated with more frequent visits, as were lower Palliative Performance Scale (PPS) scores (<40: 1.78 visits/day, 95% confidence interval [CI] 1.74-1.82 versus 40-60: 1.65 visits/day, 95% CI 1.61-1.69 versus >60: 1.41 visits/day, 95% CI 1.36-1.47; p<0.001), the presence of pain (pain: 1.77 visits/day; 95% CI 1.72-1.82 versus no pain: 1.44 visits/day, 95% CI .39-1.59; p<0.001). Patients admitted to home hospice from a hospital also received more frequent visits compared with other patients (hospital: 1.73 visits/day, 95% CI 1.67-1.79 versus home: 1.42 visits/day, 95% CI 1.40-1.44; p<0.001). Conclusions: An acuity index based on these variables could help hospices to better anticipate patient needs and staff workload, and could be used to guide strategic planning as hospices take part in accountable care organizations (ACOs).
    Journal of palliative medicine 12/2013; · 1.84 Impact Factor
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    ABSTRACT: Textbooks report that patients with ESRD survive for 7-10 days after discontinuation of dialysis. Studies describing actual survival are limited, however, and research has not defined patient characteristics that may be associated with longer or shorter survival times. The goals of this study were to determine the mean life expectancy of patients admitted to hospice after discontinuation of dialysis, and to identify independent predictors of survival time. Data for demographics, clinical characteristics, and survival were obtained from 10 hospices for patients with ESRD who discontinued dialysis before hospice admission. Data were collected for patients admitted between January 1, 2008 and May 15, 2012. All hospices were members of the Coalition of Hospices Organized to Investigate Comparative Effectiveness network, which obtains de-identified data from an electronic medical record. Of 1947 patients who discontinued dialysis, the mean survival after hospice enrollment was 7.4 days (range, 0-40 days). Patients who discontinued dialysis had significantly shorter survival compared with other patients (n=124,673) with nonrenal hospice diagnoses (mean survival 54.4 days; hazard ratio, 2.96; 95% confidence interval, 2.82 to 3.09; P<0.001). A Cox proportional hazards model identified seven independent predictors of earlier mortality after dialysis discontinuation, including male sex, referral from a hospital, lower functional status (Palliative Performance Scale score), and the presence of peripheral edema. Patients who discontinue dialysis have significantly shorter survival than other hospice patients. Individual survival time varies greatly, but several variables can be used to predict survival and tailor a patient's care plan based on estimated prognosis.
    Clinical Journal of the American Society of Nephrology 11/2013; · 5.07 Impact Factor
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    ABSTRACT: . This mixed methods study sought to evaluate the outcomes of an integrative Reiki volunteer program in an academic medical oncology center setting. . We used de-identified program evaluation data to perform both quantitative and qualitative analyses of participants' experiences of Reiki sessions. The quantitative data were collected pre- and postsession using a modified version of the distress thermometer. The pre- and postsession data from the distress assessment were analyzed using a paired Student's : test. The qualitative data were derived from written responses to open-ended questions asked after each Reiki session and were analyzed for key words and recurring themes. . Of the 213 pre-post surveys of first-time sessions in the evaluation period, we observed a more than 50% decrease in self-reported distress (from 3.80 to 1.55), anxiety (from 4.05 to 1.44), depression (from 2.54 to 1.10), pain (from 2.58 to 1.21), and fatigue (from 4.80 to 2.30) with : < .001 for all. Using conservative estimates that treat missing data as not endorsing Reiki, we found 176 (82.6%) of participants liked the Reiki session, 176 (82.6%) found the Reiki session helpful, 157 (73.7%) plan to continue using Reiki, and 175 (82.2%) would recommend Reiki to others. Qualitative analyses found that individuals reported that Reiki induced relaxation and enhanced spiritual well-being. . An integrative Reiki volunteer program shows promise as a component of supportive care for cancer patients. More research is needed to evaluate and understand the impact that Reiki may have for patients, caregivers, and staff whose lives have been affected by cancer.
    Integrative Cancer Therapies 10/2013; · 2.35 Impact Factor
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    ABSTRACT: Abstract Objective: This study examined the impact of palliative home nursing care on rates of hospital 30-day readmissions. Methods: The electronic health record based retrospective cohort study was performed within home care and palliative home care programs. Participants were home care patients discharged from one of three urban teaching hospitals. Outcome measures were propensity score matched rates of hospital readmissions within 30 days of hospital discharge. Results: Of 406 palliative home care patients, matches were identified for 392 (96%). Of 15,709 home care patients, 890 were used at least once as a match for palliative care patients, for a total final sample of 1282. Using the matched sample we calculated the average treatment effect for treated patients. In this sample, palliative care patients had a 30-day readmission probability of 9.1% compared to a probability of 17.4% in the home care group (mean ATT: 8.3%; 95% confidence interval [CI] 8.0%-8.6%). This effect persisted after adjustment for visit frequency. Conclusions: Palliative home care may offer benefits to health systems by allowing patients to remain at home and thereby avoiding 30-day rehospitalizations.
    Journal of palliative medicine 09/2013; · 1.84 Impact Factor
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    ABSTRACT: Palliative care research in Africa is in its relative infancy, with dedicated financial support extremely limited. Therefore, setting research priorities to optimize use of limited resources is imperative. To develop a prioritized research agenda for palliative care in Africa. We used a two-stage process involving palliative care professionals and researchers: 1) generation of an initial topic list at a consultative workshop of experts and 2) prioritization of that list using a consensus development process, the nominal group technique. Phase 1: 41 topics were generated across five groups, with several topics nominated in more than one group. Phase 2: 16 topics and three broad thematic areas were identified. The two most prioritized topics within each of the three themes were the following: Theme 1: patient, family, and volunteers-1) care outcomes and the impact of palliative care as perceived by patients and caregivers and 2) palliative care needs of children; Theme 2: health providers-1) impact of palliative care training on care and practice and 2) integration of palliative care and antiretroviral therapy services; and Theme 3: health systems-1) palliative care needs assessments at the micro-, meso-, and macro-levels and 2) integration of palliative care into health systems and educational curricula. Consensus-based palliative care topics determined by the study can assist researchers in optimizing limited research capacities by focusing on these prioritized areas. Subsequent to the identification and publication of the research agenda, concrete steps will be undertaken by the African Palliative Care Research Network and other partners to help implement it.
    Journal of pain and symptom management 07/2013; · 2.42 Impact Factor
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    ABSTRACT: Overuse or misuse of tests and treatments exposes patients to potential harm. The American Board of Internal Medicine Foundation's Choosing Wisely® campaign is a multiyear effort to encourage physician leadership in reducing harmful or inappropriate resource utilization. Via the campaign, medical societies are asked to identify five tests or procedures commonly used in their field, the routine use of which in specific clinical scenarios should be questioned by both physicians and patients based on the evidence that the test or procedure is ineffective or even harmful. The American Academy of Hospice and Palliative Medicine (AAHPM) was invited, and it agreed to participate in the campaign. The AAHPM Choosing Wisely Task Force, with input from the AAHPM membership, developed the following five recommendations: 1) Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral-assisted feeding; 2) Don't delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment; 3) Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care; 4) Don't recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis; and 5) Don't use topical lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®) (ABH) gel for nausea. These recommendations and their supporting rationale should be considered by physicians, patients, and their caregivers as they collaborate in choosing those treatments that do the most good and avoid the most harm for those living with serious illness.
    Journal of pain and symptom management 03/2013; 45(3):595-605. · 2.42 Impact Factor
  • Neha Jeurkar, David J Casarett
    Journal of Clinical Oncology 02/2013; 31(5):652. · 18.04 Impact Factor

Publication Stats

2k Citations
1,055.07 Total Impact Points

Institutions

  • 2004–2014
    • Hospital of the University of Pennsylvania
      • • Department of Medicine
      • • Department of Geriatric Medicine
      • • Division of Geriatrics
      • • Division of Hematology/Oncology
      Philadelphia, Pennsylvania, United States
  • 1999–2014
    • University of Pennsylvania
      • • Perelman School of Medicine
      • • Department of Medicine
      • • Center for Clinical Epidemiology and Biostatistics
      • • Center for Health Equity Research
      • • Institute on Aging
      • • Division of Geriatric Medicine
      Philadelphia, Pennsylvania, United States
  • 2013
    • University of Missouri - Kansas City
      Kansas City, Missouri, United States
    • Retreat of Lancaster County
      Ephrata, Pennsylvania, United States
  • 2011
    • Brown University
      • Alpert Medical School
      Providence, RI, United States
  • 2005
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States
  • 2002
    • Treatment Research Institute, Philadelphia PA
      Philadelphia, Pennsylvania, United States
  • 2001
    • The Philadelphia Center
      • Philadelphia Veterans Administration Medical Center
      Philadelphia, Pennsylvania, United States
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 1997
    • University of Chicago
      Chicago, Illinois, United States
    • University of Illinois at Chicago
      Chicago, Illinois, United States