Steven J Atlas

Harvard Medical School, Boston, Massachusetts, United States

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Publications (75)279.25 Total impact

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    ABSTRACT: Advances in information technology (IT) now permit population-based preventive screening, but the best methods remain uncertain. We evaluated whether involving primary care providers (PCPs) in a visit-independent population management IT application led to more effective cancer screening.
    Journal of the American Board of Family Medicine : JABFM. 07/2014; 27(4):474-85.
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    ABSTRACT: The long-term effects of interventions to improve colorectal (CRC) screening in vulnerable populations are uncertain. The authors evaluated the impact of patient navigation (PN) on the equity of CRC prevention over a 5-year period. A culturally tailored CRC screening PN program was implemented in 1 community health center (CHC) in 2007. In a primary care network, CRC screening rates from 2006 to 2010 among eligible patients from the CHC with PN were compared with the rates from other practices without PN. Multivariable logistic regression models for repeated measures were used to assess differences over time. Differences in CRC screening rates diminished among patients at the CHC with PN and at other practices between 2006 (49.2% vs 62.5%, respectively; P < .001) and 2010 (69.2% vs 73.6%, respectively; P < .001). The adjusted rate of increase over time was higher at the CHC versus other practices (5% vs 3.4% per year; P < .001). Among Latino patients at the CHC compared with other practices, lower CRC screening rates in 2006 (47.5% vs 52.1%, respectively; P = .02) were higher by 2010 (73.5% vs 67.3%, respectively; P < .001). Similar CRC screening rates among non-English speakers at the CHC and at other practices in 2006 (44.3% vs 44.7%, respectively; P = .79) were higher at the CHC by 2010 (70.6% vs 58.6%, respectively; P < .001). Adjusted screening rates increased more over time for Latino and non-English speakers at the CHC compared with other practices (both P < .001). A PN program increased CRC screening rates in a CHC and improved equity in vulnerable patients. Long-term funding of PN programs has the potential to reduce cancer screening disparities. Cancer 2014. © 2014 American Cancer Society.
    Cancer 04/2014; · 5.20 Impact Factor
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    ABSTRACT: Objective To optimize a new visit-independent, population-based cancer screening system (TopCare) by using Operations Research techniques to simulate: (1) changes in patient outreach staffing levels (delegates, navigators), (2) modifications to user workflow within the IT system, and (3) changes in cancer screening recommendations. Materials and Methods TopCare was modeled as a multi-server, multi-phase queueing system. Simulation experiments implemented the queueing network model following a next-event time-advance mechanism, where systematic adjustments were made to staffing levels, IT workflow settings, and cancer screening frequency in order to assess their impact on overdue screenings per patient. Results TopCare reduced the average number of overdue screenings per patient from 1.17 at inception to 0.86 during simulation to 0.23 at steady state. Increases in workforce improved the effectiveness of TopCare. Specifically, increasing delegate or navigator staff level by one person improved screening completion rates by 1.3% or 12.2%, respectively. In contrast, changes in the amount of time a patient entry stays on delegate and navigator lists had little impact on overdue screenings. Finally, lengthening the screening interval increased efficiency within TopCare by decreasing overdue screenings at the patient level, resulting in a smaller number of overdue patients needing delegates for screening and a higher fraction of screenings completed by delegates. Conclusions Simulating the impact of changes in staffing, system parameters, and clinical inputs on the effectiveness and efficiency of care can inform the allocation of limited resources in population management.
    Journal of the American Medical Informatics Association 01/2014; 21:e129-e135. · 3.57 Impact Factor
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    ABSTRACT: To determine whether frequent emergency department (ED) users are more likely to make at least one and a majority of visits for mental health, alcohol, or drug-related complaints compared to non-frequent users. We performed a retrospective cohort study exploring frequent ED use and ED diagnosis at a single, academic hospital and included all ED patients between January 1 and December 31, 2010. We compared differences in ED visits with a primary International Classification of Diseases, 9th Revision visit diagnosis of mental health, alcohol or drug-related diagnoses between non-frequent users (<4 visits during previous 12-months) and frequent (repeat [4-7 visits], highly frequent [8-18 visits] and super frequent [≥19 visits]) users in univariate and multivariable analyses. Frequent users (2496/65201 [3.8%] patients) were more likely to make at least one visit associated with mental health, alcohol, or drug-related diagnoses. The proportion of patients with a majority of visits related to any of the three diagnoses increased from 5.8% among non-frequent users (3616/62705) to 9.4% among repeat users (181/1926), 13.1% among highly frequent users (62/473), and 25.8% (25/97 patients) in super frequent users. An increasing proportion of visits with alcohol-related diagnoses was observed among repeat, highly frequent, and super frequent users but was not found for mental health or drug-related complaints. Frequent ED users were more likely to make a mental health, alcohol or drug-related visit, but a majority of visits were only noted for those with alcohol-related diagnoses. To address frequent ED use, interventions focusing on managing patients with frequent alcohol-related visits may be necessary.
    The American journal of emergency medicine 09/2013; · 1.54 Impact Factor
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    ABSTRACT: BACKGROUND: Patient navigator (PN) programs can improve breast cancer screening in low income, ethnic/racial minorities. Refugee women have low breast cancer screening rates, but it has not been shown that PN is similarly effective. OBJECTIVE: Evaluate whether a PN program for refugee women decreases disparities in breast cancer screening. DESIGN: Retrospective program evaluation of an implemented intervention. PARTICIPANTS: Women who self-identified as speaking Somali, Arabic, or Serbo-Croatian (Bosnian) and were eligible for breast cancer screening at an urban community health center (HC). Comparison groups were English-speaking and Spanish-speaking women eligible for breast cancer screening in the same HC. INTERVENTION: Patient navigators educated women about breast cancer screening, explored barriers to screening, and tailored interventions individually to help complete screening. MAIN MEASURES: Adjusted 2-year mammography rates from logistic regression models for each calendar year accounting for clustering by primary care physician. Rates in refugee women were compared to English-speaking and Spanish-speaking women in the year before implementation of the PN program and over its first 3 years. RESULTS: There were 188 refugee (36 Somali, 48 Arabic, 104 Serbo-Croatian speaking), 2,072 English-speaking, and 2,014 Spanish-speaking women eligible for breast cancer screening over the 4-year study period. In the year prior to implementation of the program, adjusted mammography rates were lower among refugee women (64.1 %, 95 % CI: 49-77 %) compared to English-speaking (76.5 %, 95 % CI: 69 %-83 %) and Spanish-speaking (85.2 %, 95 % CI: 79 %-90 %) women. By the end of 2011, screening rates increased in refugee women (81.2 %, 95 % CI: 72 %-88 %), and were similar to the rates in English-speaking (80.0 %, 95 % CI: 73 %-86 %) and Spanish-speaking (87.6 %, 95 % CI: 82 %-91 %) women. PN increased screening rates in both younger and older refugee women. CONCLUSION: Linguistically and culturally tailored PN decreased disparities over time in breast cancer screening among female refugees from Somalia, the Middle East and Bosnia.
    Journal of General Internal Medicine 05/2013; · 3.28 Impact Factor
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    ABSTRACT: Objectives: To assess the ability of a health information technology system to facilitate population- based breast cancer screening. Study Design: Cohort study with 2-year follow-up after a 1-year cluster randomized trial. Methods: Study population was women 42 to 69 years old receiving care within a 12-practice primary care network. The management informatics system (1) identified women overdue for mammograms, (2) connected them to primary care providers using a web-based tool, (3) created automatically generated outreach letters for patients specified by providers, (4) monitored for subsequent mammography scheduling and completion, and (5) provided practice delegates with a list of women remaining unscreened for reminder phone calls. Eligible women overdue for a mammogram during a 1-year study period included those overdue at study start (prevalent cohort) and those who became overdue during follow-up (incident cohort). The main outcome measure was mammography completion rates over 3 years. Results: Among 32,688 eligible women, 9795 (30%) were overdue for screening (4487 intervention, 5308 control). Intervention patients were somewhat younger, more likely to be non-Hispanic white, and more likely to have health insurance compared with control patients. Adjusted completion rates in the prevalent cohort (n = 6697) were significantly higher among intervention patients after 3 years (51.7% vs 45.8%; P = .002). For patients in the incident cohort (n = 3098), adjusted completion rates after 2 years were 53.8% versus 48.7%, respectively (P = .052). Conclusions: Population-based informatics systems can enable sustained increases in mammography screening rates beyond rates seen with office-based visit reminders.
    The American journal of managed care 12/2012; 18(12):821-9. · 2.12 Impact Factor
  • Archives of internal medicine 05/2012; 172(10):821-3. · 11.46 Impact Factor
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    ABSTRACT: Retrospective and prospective patient surveys and a physician survey using a sample from American Medical Association master file. To evaluate the performance of a new instrument designed to measure the quality of decisions about treatment of herniated disc. There is growing consensus on the importance of engaging and informing patients to improve the quality of significant medical decisions, yet there are no instruments currently available to measure decision quality. The herniated disc-decision quality instrument (HD-DQI) was developed with input from clinical experts, survey research experts, and patients. The HD-DQI produces 2 scores each scaled to 0% to 100%, with higher scores indicating better quality: (1) a total knowledge score and (2) a concordance score (indicating the percentage of patients who received treatments that matched their goals). We examined hypotheses relating to the acceptability, feasibility, validity, and reliability of the instrument, using data from 3 samples. The HD-DQI survey was feasible to implement and acceptable to patients, with good response rates and low missing data. The knowledge score discriminated between patients who had seen a decision aid or no decision aid (55% vs. 38%, P < 0.001) and between providers and patients (73% vs. 46%, P < 0.001). The knowledge score also had good retest reliability (intraclass correlation coefficient = 0.85). Most patients (78%) received treatments that matched their goals. Patients who received treatments that matched their goals were less likely to regret the decision than those who did not (13% vs. 39%, P = 0.004). The HD-DQI met several criteria for high-quality patient-reported survey instruments. It can be used to determine the quality of decisions for treatment of herniated disc. More work is needed to examine acceptability for use as part of routine patient care.
    Spine 03/2012; 37(18):1609-16. · 2.16 Impact Factor
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    ABSTRACT: To examine patient and physician factors affecting utilization of diagnostic imaging in primary care. Patient-level data from a large academic group practice over the period July 1, 2007, through June 30, 2009. This is a retrospective cohort study of 85,277 patients cared for by 148 primary care physicians (PCPs). The dependent variable is the number of outpatient imaging exams ordered by each patient's PCP over the study period. Independent variables include 17 patient factors describing both clinical need and demographic characteristics and 7 physician factors. Data were collected from the electronic medical record and associated administrative databases. Patient factors having a statistically significant effect on both the probability race, more than 10 medications, congestive heart failure, diabetes, hypertension, other problems, visits to the PCP, visits to specialists, and imaging exams ordered by specialists. For physician factors, experience, gender, and having another degree were statistically significant in both portions of the model. Both patient and physician factors have a substantial effect on primary care outpatient diagnostic imaging utilization. Several of these significantly influence both the probability that any images will be ordered and the intensity (number) of imaging.
    The American journal of managed care 01/2012; 18(4):e135-44. · 2.12 Impact Factor
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    Steven Atlas, Jonathan S. Skinner
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    ABSTRACT: No abstract available.
    NBER Book Chapters. 12/2011;
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    ABSTRACT: As guidelines proliferate and are used to inform efforts to improve the quality and efficiency of care, disputes over guideline recommendations are likely to become more common and contentious. It is appropriate for guidelines to come under close scrutiny, given their important clinical and policy implications, and critiques that point out missing evidence, improper methods, or errors in interpretation can be valuable. But for critiques to be valid, they should be based on accurate information and a sound scientific basis. A 2009 guideline sponsored by the American Pain Society (APS) on the use of invasive tests and interventional procedures found insufficient evidence to make recommendations for most interventional procedures. It was subsequently the subject of lengthy critiques by the American Society of Interventional Pain Physicians (ASIPP) that sought to challenge the methods used to develop the APS guideline, point out alleged errors in the evidence review commissioned to inform the guideline, and question the integrity of the APS guideline process. We show that the ASIPP critiques contain numerous errors and fail to adhere to scientific standards for reviewing evidence, and provide suggestions on how future disputes regarding guidelines might be addressed in a more constructive manner. PERSPECTIVE: In order to best serve patients and clinicians, debates over guidelines should be based on accurate information, adhere to current methodological standards, acknowledge important deficiencies in the evidence when they are present, and handle conflicts of interest in a vigorous and transparent manner.
    The journal of pain: official journal of the American Pain Society 08/2011; 12(8):833-9. · 3.78 Impact Factor
  • Steven J Atlas
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    ABSTRACT: COMMENTARY ON: Athiviraham A, Wali ZA, Yen D. Predictive factors influencing clinical outcome with operative management of spinal stenosis. Spine J 2011;11:613-7 (in this issue).
    The spine journal: official journal of the North American Spine Society 07/2011; 11(7):620-1. · 2.90 Impact Factor
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    ABSTRACT: Information technology offers the promise, as yet unfulfilled, of delivering efficient, evidence-based health care. To evaluate whether a primary care network-based informatics intervention can improve breast cancer screening rates. Cluster-randomized controlled trial of 12 primary care practices conducted from March 20, 2007 to March 19, 2008. Women 42-69 years old with no record of a mammogram in the prior 2 years. In intervention practices, a population-based informatics system was implemented that: connected overdue patients to appropriate care providers, presented providers with a Web-based list of their overdue patients in a non-visit-based setting, and enabled "one-click" mammography ordering or documented deferral reasons. Patients selected for mammography received automatically generated letters and follow-up phone calls. All practices had electronic health record reminders about breast cancer screening available during clinical encounters. The primary outcome was the proportion of overdue women undergoing mammography at 1-year follow-up. Baseline mammography rates in intervention and control practices did not differ (79.5% vs 79.3%, p = 0.73). Among 3,054 women in intervention practices and 3,676 women in control practices overdue for mammograms, intervention patients were somewhat younger, more likely to be non-Hispanic white, and have health insurance. Most intervention providers used the system (65 of 70 providers, 92.9%). Action was taken for 2,652 (86.8%) intervention patients [2,274 (74.5%) contacted and 378 (12.4%) deferred]. After 1 year, mammography rates were significantly higher in the intervention arm (31.4% vs 23.3% in control arm, p < 0.001 after adjustment for baseline differences; 8.1% absolute difference, 95% CI 5.1-11.2%). All demographic subgroups benefited from the intervention. Intervention patients completed screening sooner than control patients (p < 0.001). A novel population-based informatics system functioning as part of a non-visit-based care model increased mammography screening rates in intervention practices. ClinicalTrials.gov; NCT00462891.
    Journal of General Internal Medicine 02/2011; 26(2):154-61. · 3.28 Impact Factor
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    ABSTRACT: Lower rates of follow-up after an abnormal Pap smear in racial and ethnic minorities may contribute to the higher incidence and mortality rates of cervical cancer seen in these groups. To identify patient-perceived barriers to follow-up after an abnormal Pap smear result among Latina women. DESIGN, PARTICIPANTS AND APPROACH: Qualitative, semi-structured, one-on-one interviews were conducted with patients from an academic hospital-affiliated urban community health center. Three groups of women were interviewed: new colposcopy clinic patients, patients who had previous colposcopies and patients enrolled in the health center's patient navigator program. Open-ended questions explored their knowledge, beliefs and experiences with colposcopy. Content analysis of transcripts was performed using established qualitative techinques. Of 40 Latina women recruited, 75% spoke only Spanish. The average age was 31.5 (range 18-55). Personal and system barriers identified were categorized into four themes: (1) anxiety/fear of procedure and diagnosis; (2) scheduling/availability of appointments interfering with work and/or child care; (3) inadequate communication about appointments, including lack of explanation regarding diagnosis, procedure and results; and (4) pain. New patients more commonly reported problems with scheduling and communication. Follow-up patients were more concerned about pain, and navigated women most often reported fear of results but had fewer concerns about inadequate communication. Anxiety/fear was the most common personal barrier, while difficulty scheduling appointments and inadequate communication were the major systems barriers identified in these Latina women. Interventions to lower these barriers to colposcopy among Latina women may increase adherence to follow-up of abnormal Pap smears.
    Journal of General Internal Medicine 11/2010; 25(11):1198-204. · 3.28 Impact Factor
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    ABSTRACT: Physicians have increasingly become the focus of clinical performance measurement. To investigate the relationship between patient panel characteristics and relative physician clinical performance rankings within a large academic primary care network. Cohort study using data from 125,303 adult patients who had visited any of the 9 hospital-affiliated practices or 4 community health centers between January 1, 2003, and December 31, 2005, (162 primary care physicians in 1 physician organization linked by a common electronic medical record system in Eastern Massachusetts) to determine changes in physician quality ranking based on an aggregate of Health Plan Employer and Data Information Set (HEDIS) measures after adjusting for practice site, visit frequency, and patient panel characteristics. Composite physician clinical performance score based on 9 HEDIS quality measures (reported by percentile, with lower scores indicating higher quality). Patients of primary care physicians in the top quality performance tertile compared with patients of primary care physicians in the bottom quality tertile were older (51.1 years [95% confidence interval {CI}, 49.6-52.6 years] vs 46.6 years [95% CI, 43.8-49.5 years], respectively; P < .001), had a higher number of comorbidities (0.91 [95% CI, 0.83-0.98] vs 0.80 [95% CI, 0.66-0.95]; P = .008), and made more frequent primary care practice visits (71.0% [95% CI, 68.5%-73.5%] vs 61.8% [95% CI, 57.3%-66.3%] with >3 visits/year; P = .003). Top tertile primary care physicians compared with the bottom tertile physicians had fewer minority patients (13.7% [95% CI, 10.6%-16.7%] vs 25.6% [95% CI, 20.2%-31.1%], respectively; P < .001), non-English-speaking patients (3.2% [95% CI, 0.7%-5.6%] vs 10.2% [95% CI, 5.5%-14.9%]; P <.001), and patients with Medicaid coverage or without insurance (9.6% [95% CI, 7.5%-11.7%] vs 17.2% [95% CI, 13.5%-21.0%]; P <.001). After accounting for practice site and visit frequency differences, adjusting for patient panel factors resulted in a relative mean change in physician rankings of 7.6 percentiles (95% CI, 6.6-8.7 percentiles) per primary care physician, with more than one-third (36%) of primary care physicians (59/162) reclassified into different quality tertiles. Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary care physicians.
    JAMA The Journal of the American Medical Association 09/2010; 304(10):1107-13. · 29.98 Impact Factor
  • Article: Letters.
    Spine 09/2010; 35(19):1826-7. · 2.16 Impact Factor
  • Steven J Atlas
    Spine 09/2010; 35(19):1818-9. · 2.16 Impact Factor
  • Article: Letters.
    Roger Chou, Richard W Rosenquist, Steven J Atlas
    Spine 04/2010; 35(7):841-2. · 2.16 Impact Factor
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    Stephane Genevay, Steven J Atlas
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    ABSTRACT: Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.
    Best practice & research. Clinical rheumatology 04/2010; 24(2):253-65. · 2.90 Impact Factor
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    Steven J Atlas
    Spine 01/2010; 35(1):116. · 2.16 Impact Factor

Publication Stats

3k Citations
279.25 Total Impact Points

Institutions

  • 1996–2014
    • Harvard Medical School
      Boston, Massachusetts, United States
    • University of Maine at Augusta
      Augusta, Maine, United States
  • 1994–2014
    • Massachusetts General Hospital
      • • Laboratory of Computer Science
      • • Department of Orthopaedic Surgery
      • • Department of Medicine
      Boston, MA, United States
  • 2004–2013
    • Partners HealthCare
      Boston, Massachusetts, United States
    • Brigham and Women's Hospital
      Boston, Massachusetts, United States
  • 2010
    • University of Geneva
      • Division of Rheumatology
      Genève, GE, Switzerland
  • 2008
    • Liberty Mutual Research Institute for Safety
      Boston, Massachusetts, United States
  • 2007
    • Johns Hopkins University
      • Department of Psychiatry and Behavioral Sciences
      Baltimore, MD, United States
  • 2001
    • Boston University
      • Department of Medicine
      Boston, MA, United States
  • 2000
    • Mount Sinai Hospital
      New York City, New York, United States
  • 1998
    • Hospital of the University of Pennsylvania
      • Department of General Internal Medicine
      Philadelphia, Pennsylvania, United States