Ciaran S. Phibbs's research while affiliated with VA Palo Alto Health Care System and other places
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Publications (211)
Background:
In contrast to other high-resource countries, the US has experienced increases in the rates of severe maternal morbidity. The US also has pronounced racial/ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people.
Objective(s):
The objective of thi...
Introduction
Pregnant veterans with post-traumatic stress disorder (PTSD) are at increased risk for spontaneous preterm birth, yet the underlying reasons are unclear. We examined factors associated with spontaneous preterm birth among pregnant veterans with active PTSD.
Methods
This was an observational study of births from administrative database...
Introduction
A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk...
Objective
Given that regionalization of extremely preterm births (EPTBs) is associated with improved infant outcomes, we assessed between-hospital variation in EPTB stratified by hospital level of neonatal care, and determined the proportion of variance explained by differences in maternal and hospital factors.
Study design
We assessed 7,046,253 b...
Background
The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care.
Objective
Compare gynecologist supply in veterans’ county of residence versus at their VA site.
Design
We identified women veteran VA patie...
The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed...
This cohort study examines changes in the use of Veterans Affairs (VA) and non-VA hospitals by VA enrollees and mortality associated with these policies.
Objective
To examine the relative contributions of preterm delivery and congenital anomalies to neonatal mortality.
Study design
Retrospective analysis of 2009–2011 linked birth cohort-hospital discharge files for California, Missouri, Pennsylvania and South Carolina. Deaths were classified by gestational age and three definitions of congenital an...
Objective
To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity.
Study design
Secondary data analysis using California linked birth certificate-patient discharge data for 2009–2011 (N = 1,260,457). Regression models wer...
Objective:
To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which...
While prematurity is a major cause of neonatal mortality, morbidity, and lifelong impairment, the degree of prematurity is usually defined by the gestational age (GA) at delivery rather than by neonatal morbidity. Here we propose a multi-task deep neural network model that simultaneously predicts twelve neonatal morbidities, as the basis for a new...
Introduction
Little is known about access to and use of prenatal care by veterans using U.S. Department of Veterans Affairs (VA) maternity benefits. We compared the timeliness and adequacy of prenatal care by veteran status and payor.
Study Design
We used VA clinical and admistrative data linked with California vital statistics patient discharge d...
Introduction
The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.
Methods
California linked...
Regionalized care reduces neonatal morbidity and mortality. This study evaluated the association of patient characteristics with quantitative differences in neonatal transport networks.
We retrospectively analyzed prospectively collected data for infants <28 days of age acutely transported within California from 2008 to 2012. We generated graphs re...
Objectives
To examine the characteristics of safety net (sn) and non-safety net neonatal intensive care units (NICUs) in California and whether the site of care is associated with clinical outcomes.
Study design
This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22,081 infants born between 2014-2018 with bi...
Importance:
Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.
Objective:
To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.
Design, setting, and participants:
This retrospective population-based cohort stu...
Objective:
To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity.
Data sources/study setting:
Longitudinal secondary data from October, 2002 through September, 2006 for 215 ICUs...
Introduction:
Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be e...
Importance
New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home—that is, c...
Background:
Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core te...
Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to prese...
Our objective was to incorporate social and built environment factors into a compendium of multilevel factors among a cohort of very low birth weight infants to understand their contributions to inequities in NICU quality of care and support providers and NICUs in addressing these inequities via development of a health equity dashboard.
We examined...
To examine interhospital variation in admissions to neonatal intensive care units (NICU) and reasons for the variation.
2010–2012 linked birth certificate and hospital discharge data from 35 hospitals in California on live births at 35–42 weeks gestation and ≥1500 g birth weight were used. Hospital variation in NICU admission rates was assessed by...
Objective
To assess the relationship of moderate and late preterm birth (32–36 6/7 weeks) to long-term educational outcomes.
Study design
We hypothesized that moderate and late preterm birth would be associated with adverse outcomes in elementary school. To test this, we linked vital statistics-patient discharge data from the Office of Statewide H...
Objective
To examine the hypothesis that increasing rates and differential uptake of antenatal steroids (would bias estimation of impact of ANS on neonatal death and severe (grade III-IV) intraventricular hemorrhage (IVH).
Study design
The study population included infants born between 24 to 28 weeks gestational age in the California Perinatal Qua...
Background
Process mapping is often used in quality improvement work to examine current processes and workflow and to identify areas to intervene to improve quality. Our objective in this paper is to describe process maps as a visual means of understanding modifiable behaviors and activities, in this case example to ensure that goals of care conver...
https://apha.confex.com/apha/2020/meetingapp.cgi/Paper/471700
Over the last 15 years, the United States has experienced major increases in the rates of severe maternal morbidity (SMM) or maternal “near misses.” Initial estimates of the costs of SMM have used delivery hospitalization data, which exclude physician costs and hospital readmissions from the estimates. The objective of this study was to expand exis...
Research Objective
Similar to maternal mortality, the United States has experienced increases in the rates of severe maternal morbidity (SMM) and has pronounced racial/ethnic disparities in SMM, with non‐Hispanic Black (NHB) women having twice the rate as non‐Hispanic White (NHW) women. This study further examined these racial/ethnic disparities, l...
Research Objective
Department of Veterans Affairs (VA) Home‐Based Primary Care (HBPC) employing mobile interdisciplinary teams (IDT: physician/nurse practitioner, nurse, therapist, social worker, dietician, pharmacist, and psychologist) has been reported to be effective at improving care and lowering cost for frail, high‐risk Veterans. The full IDT...
Research Objective
The Veterans Health Administration uses structured goals‐of‐care conversations (GoCCs) to document veterans’ preferences for life‐sustaining treatments (LST). Responses include information on decision making capacity, goals, and preferences for LST following cardiopulmonary and noncardiopulmonary events. Durable medical orders ar...
Objective
The objective was to compare differences in body mass index (BMI) calculated with self‐reported versus clinically measured pre‐conception data from women veterans in California.
Methods
Veterans Health Administration (VHA) and California state birth certificate data was used to develop a cohort of women who gave birth from 2007‐2012 and...
Regionalization, which emphasizes matching patient needs with the capabilities of the hospital in which care is provided, has long been a recommended approach to reducing neonatal morbidity and mortality. Over the past decade, research methods surrounding the measurement and evaluation of such programs have improved, thus strengthening arguments fo...
Background
On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans’ goals and decisions using a standardized LST template...
Objective:
To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.
Data sources:
Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases....
Objective:
The objective of this study was to evaluate whether incorporating historical clinical information beyond 1 year improves risk adjustment.
Data sources:
Administrative data from the Department of Veterans Affairs and Medicare (for veterans concurrently enrolled in Medicare) for fiscal years (FYs) 2011-2015.
Study design:
We regressed...
Objectives:
To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers.
Methods:
Infants 22 to 29 weeks' gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the Un...
Background
Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery...
Importance:
Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear.
Objective:
To determine the extent of segregation and inequality of care of very low-birth-weight and very...
Background:
Not much is known about nonelderly veterans and their reliance on care from the Veterans Affairs (VA) health care system when they have access to non-VA care.
Objectives:
To estimate VA reliance for nonelderly veterans enrolled in VA and Medicaid.
Research design:
Retrospective, longitudinal analysis of Medicaid claims data and VA...
Background: Use of a claims-based index to identify persons with physical function impairment and at risk for long-term institutionalization would facilitate population health and comparative effectiveness research. The JEN Frailty Index [JFI] is comprised of diagnosis domains representing impairments and multimorbid clusters with high
long-term in...
GeriPACTs are geriatric-focused primary care teams with lower caseloads (2/3 of regular primary care (PACT)) and additional team members (e.g., pharmacy) to address the complex needs of patients with potentially higher need for geriatric and extended care services. We examined the effect of GeriPACT on total VA healthcare expenditures. Veterans in...
Objective
To examine Veterans Health Administration (VA) enrollees' use of VA services for treatment of behavioral health conditions (BHCs) after gaining Medicaid, and if VA reliance varies by complexity of BHCs.
Data Sources/Study Setting
VA and Medicaid Analytic eXtract utilization data from 31 states, 2006‐2010.
Study Design
A retrospective, l...
Objective:
To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.
Study design:
We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (9...
Objective
To describe variation in payer and outcomes in Veterans’ births.
Data/Setting
Secondary data analyses of deliveries in California, 2000–2012.
Study Design
We performed a retrospective, population‐based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and...
Objectives
To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data.
Data Sources
VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013.
Study Design
Analyses were conducted with VH...
Objectives
To compare the quality of end‐of‐life care in Medicare Advantage (MA) and traditional Medicare (TM), specifically, receipt and length of hospice care.
Design
Retrospective analysis of administrative data.
Setting
Hospice care.
Participants
Veterans dually enrolled in the Veterans Health Administration (VHA) and MA or TM who died betwe...
Importance
Treatment-resistant major depression (TRMD) in veterans is a major clinical challenge given the high risk for suicidality in these patients. Repetitive transcranial magnetic stimulation (rTMS) offers the potential for a novel treatment modality for these veterans.
Objective
To determine the efficacy of rTMS in the treatment of TRMD in v...
Objectives
To examine hospital readmissions, costs, mortality, and nursing home admissions of veterans who received Hospital‐in‐Home (HIH) services.
Design
Retrospective cohort study.
Setting
Cincinnati Veterans Affairs Medical Center (VAMC).
Participants
Study cohort included veterans who received HIH services as an alternative to inpatient car...
Background:
It is unknown whether treatment costs of Keratinocyte Carcinoma (KC) and Actinic Keratosis (AK) can be lowered by spending more on chemoprevention.
Objective:
We examine the impact of one-course treatment of topical fluorouracil on the face and ears on KC and AK treatment costs over three years.
Methods:
The VAKCC trial compared th...
With increasing integration of women into combat roles in the United States military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined if deployment increases the risk of preterm birth; no studies have examined a recent cohort of...
The United States Department of Veterans Affairs (VA) is facing pressures to rebalance its long-term care system. Using VA administrative data from 2004–2011, we describe changes in the VA’s nursing homes (called Community Living Centers [CLCs]) following enactment of directives intended to shift CLCs’ focus from providing long-term custodial care...
The study by Howell et al¹ in this issue of JAMA Pediatrics is a carefully done, methodologically sound examination of the racial/ethnic disparities in the outcomes for very preterm infants in New York City. The authors partitioned the racial/ethnic differences in a combined morbidity and mortality index into those attributable to maternal and infa...
Studies have shown that hospitalizations of nursing home (NH) residents lead to complications and poorer quality of life. The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement (QI) Program assists licensed NH staff in avoiding such hospitalizations. INTERACT aims to improve the management of acute changes in residents' con...
Background
Evaluation of repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression (TRMD) in Veterans offers unique clinical trial challenges. Here we describe a randomized, double-blinded, intent-to-treat, two-arm, superiority parallel design, a multicenter study funded by the Cooperative Studies Program (CSP No....
Background:
Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.
Methods:
Prospective observational analysis of 18 616...
Objectives:
To examine the outcomes (ie, costs, hospitalizations, and mortality) associated with a Hospital-in-Home (HIH) program implemented in 2010 by the Veterans Affairs (VA) Pacific Islands Healthcare System in Honolulu, Hawaii.
Study design:
Retrospective cohort study.
Methods:
We obtained medical information for veterans who were enroll...
VA Office of Geriatrics & Extended Care established Geriatric Patient-Aligned Care teams (GeriPACT) with team members (pharmacy, and social work) added to the panels, and panels 2/3 the size of most VA primary care teams, to better manage aged and frail Veterans. We evaluated GeriPACT effect on expenditures among Veterans with >2 diagnoses based se...
This study evaluated the impact of the Veterans’ Health Administrations’ (VHA) Comprehensive End of Life Initiative (CELCI) enacted in 2009, which financed VA medical center-affiliated hospice units and hospice and palliative care staffing, training, quality monitoring and community outreach. Data from VHA utilization, vital status and enrollment f...
HBPC has expanded to serve 53,000 veterans in 2015. HBPC provides interdisciplinary team (physician, nursing, pharmacy, dietary, therapy, psychology, social work) care at home for frail Veterans (24% annual mortality, average 5 diagnoses based self-care capacity limitations [JEN Frailty index (JFI) mean 5.4]). Applying Independence at Home Qualifyi...
In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, an...
As around the world, the Veterans Health Administration’s Office of Geriatrics & Extended Care has been developing and promoting non-institutional care (GEC NIC) in order to provide Veteran-aligned care, better access to services, care coordination and to balance quality and budget. Each of 141 medical centers has adopted GEC programs with penetrat...
Objectives:
To examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care.
Data sources:
Veterans Affairs utilization data and Medicaid Analytic Extract Files.
Study design:
A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2...
Background:
The RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial found triple therapy to be noninferior to etanercept-methotrexate in patients with active rheumatoid arthritis (RA).
Objective:
To determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy.
Design:
A within-trial a...
Background:
NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.
Methods:
Provider perceptions of burnout...
Objective:
The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network.
Study design:
This cross-sectional database study included 654...
Background:
Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.
Methods:
This retrospective cohort analysis of all Veterans H...
Background
Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. Objectives
To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA...
Objective
To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).
Methods
We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evalua...
Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively), but can cause hemorrhage. The time in International Normalized Ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relationship between baseline stroke, bleeding risk and...
Background:
The Veterans Health Administration (VHA) provides health care to large numbers of veterans afflicted with keratinocyte carcinoma (KC).
Objective:
To estimate the number of veterans treated for KCs and the related diagnosis, actinic keratosis (AK) and the costs of treating these conditions over a 1-year period.
Materials and methods:...
