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Rose DE, Leung LB, McClean M, Nelson KM, Curtis I, Yano EM, Rubenstein LV, Stockdale SE. Associations Between Primary Care Providers and Staff-Reported Access Management Challenges and Patient Perceptions of Access. J Gen Intern Med 2023; 38:2870-2878. [PMID: 37532877 PMCID: PMC10593665 DOI: 10.1007/s11606-023-08172-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 03/13/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND/OBJECTIVE Optimizing patients' access to primary care is critically important but challenging. In a national survey, we asked primary care providers and staff to rate specific care processes as access management challenges and assessed whether clinics with more of these challenges had worse access outcomes. METHODS Study design: Cross sectional. National Primary Care Personnel Survey (NPCPS) (2018) participants included 6210 primary care providers (PCPs) and staff in 813 clinics (19% response rate) and 158,645 of their patients. We linked PCP and staff ratings of access management challenges to veterans' perceived access from 2018-2019 Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (SHEP-PCMH) surveys (35.6% response rate). MAIN MEASURES The NPCPS queried PCPs and staff about access management challenges. The mean overall access challenge score was 28.6, SD 6.0. The SHEP-PCMH access composite asked how often veterans reported always obtaining urgent appointments same/next day; routine appointments when desired and having medical questions answered during office hours. ANALYTIC APPROACH We aggregated PCP and staff responses to clinic level, and use multi-level, multivariate logistic regressions to assess associations between clinic-level access management challenges and patient perceptions of access. We controlled for veteran-, facility-, and area-level characteristics. KEY RESULTS Veterans at clinics with more access management challenges (> 75th percentile) had a lower likelihood of reporting always receiving timely urgent care appointments (AOR: .86, 95% CI: .78-.95); always receiving routine appointments (AOR: .74, 95% CI: .67-.82); and always reporting same- or next-day answers to telephone questions (AOR: .79, 95% CI: .70-.90) compared to veterans receiving care at clinics with fewer (< 25th percentile) challenges. DISCUSSION/CONCLUSION Findings show a strong relationship between higher levels of access management challenges and worse patient perceptions of access. Addressing access management challenges, particularly those associated with call center communication, may be an actionable path for improved patient experience.
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Affiliation(s)
- Danielle E Rose
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Lucinda B Leung
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Michael McClean
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Karin M Nelson
- VA Puget Sound Healthcare System, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - Elizabeth M Yano
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Fielding School of Public Health, UCLA, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Susan E Stockdale
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
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Rose DE, Oishi SM, Farmer MM, Bean-Mayberry B, Canelo I, Washington DL, Yano EM. Association Between Availability of Women's Health Services and Women Veterans' Care Experiences. Womens Health Issues 2022; 32:623-632. [PMID: 36115812 DOI: 10.1016/j.whi.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 07/11/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. METHODS In a cross-sectional analysis, we linked Fiscal Year 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Health care Experiences of Patients-Patient Centered Medical Home (2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics. RESULTS A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99). CONCLUSION For the most part, routine availability of women's health services in VA primary care clinics enhanced women's health care experiences. These empirical findings offer health care leaders evidence-based approaches for improving women's care experiences.
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Affiliation(s)
- Danielle E Rose
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California.
| | - Sabine M Oishi
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
| | - Melissa M Farmer
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
| | - Bevanne Bean-Mayberry
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Ismelda Canelo
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, California
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Ginting ML, Wong CH, Lim ZZB, Choo RWM, Carlsen SCH, Sum G, Vrijhoef HJM. A Patient-Centred Medical Home Care Model for Community-Dwelling Older Adults in Singapore: A Mixed-Method Study on Patient's Care Experience. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084778. [PMID: 35457642 PMCID: PMC9030670 DOI: 10.3390/ijerph19084778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023]
Abstract
Patient-Centred Medical Home (PCMH) is a strategy to enhance patient-centredness to improve care experience. We aimed to understand patient experience of an integrated PCMH model for complex community-dwelling older adults in Singapore. We used a mixed-method design with a prospective single-group pre-post quantitative component and a concurrent qualitative component. Participants were administered the validated Consumer Assessment of Health Providers and Systems Clinician & Group Survey (CG-CAHPS) at baseline (N = 184) and 6-month (N = 166) post-enrolment. We conducted focus group discussions (FGDs) on a purposive sample of 24 participants. Both methods suggest better care experience in PCMH relative to usual care. There were improvements in the CG-CAHPS measures on patient–provider communication, care coordination, office staff interactions, support for patients in caring for their own health, and provider rating in PCMH relative to usual care. In the FGDs, participants reported benefits of consolidated appointments and positive experience in sustained patient–provider relationship, shared-decision making, and family/caregiver engagement in PCMH. Participants may not fully comprehend the concept of integrated care, hindering both the effective communication of the intended care model and perceived benefits such as the provision of multidisciplinary team-based care.
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Affiliation(s)
- Mimaika Luluina Ginting
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (C.H.W.); (Z.Z.B.L.); (R.W.M.C.); (S.C.H.C.); (G.S.)
- Correspondence:
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (C.H.W.); (Z.Z.B.L.); (R.W.M.C.); (S.C.H.C.); (G.S.)
- Tsao Foundation, Singapore 168730, Singapore
- Health Services & Systems Research, Duke-NUS, Singapore 169857, Singapore
| | - Zoe Zon Be Lim
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (C.H.W.); (Z.Z.B.L.); (R.W.M.C.); (S.C.H.C.); (G.S.)
| | - Robin Wai Munn Choo
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (C.H.W.); (Z.Z.B.L.); (R.W.M.C.); (S.C.H.C.); (G.S.)
| | - Sheena Camilla Hirose Carlsen
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (C.H.W.); (Z.Z.B.L.); (R.W.M.C.); (S.C.H.C.); (G.S.)
| | - Grace Sum
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (C.H.W.); (Z.Z.B.L.); (R.W.M.C.); (S.C.H.C.); (G.S.)
| | - Hubertus Johannes Maria Vrijhoef
- Panaxea, B.V., 1098 XH Amsterdam, The Netherlands;
- Department of Patient & Care, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
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Weiss L, Griffin K, Wu M, DeGarmo E, Jasani F, Pagán JA. Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research. J Prim Care Community Health 2022; 13:21501319221112588. [PMID: 35847997 PMCID: PMC9290170 DOI: 10.1177/21501319221112588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: The patient-centered medical home (PCMH) model, an important component of healthcare transformation in the United States, is an approach to primary care delivery with the goal of improving population health and the patient care experience while reducing costs. PCMH research most often focuses on system level indicators including healthcare use and cost; descriptions of patient and provider experience with PCMH are relatively sparse and commonly limited in scope. This study, part of a mixed-methods evaluation of a multi-year New York State initiative to refine and expand the PCMH model, describes patient and provider experience with New York State PCMH and its key components. Methods: The qualitative component of the evaluation included focus groups with patients of PCMH practices in 5 New York State counties (n = 9 groups and 67 participants) and interviews with providers and practice administrators at New York State PCMH practices (n = 9 interviews with 10 participants). Through these focus groups and interviews, we elicited first-person descriptions of experiences with, as well as perspectives on, key components of the New York State PCMH model, including accessibility, expanded use of electronic health records, integration of behavioral health care, and care coordination. Results: There was evident progress and some satisfaction with the PCMH model, particularly regarding integrated behavioral health and, to some extent, expanded use of electronic health records. There was less evident progress with respect to improved access and reasonable wait times, which caused patients to continue to use urgent care or the emergency department as substitutes for primary care. Conclusions: It is critical to understand the strengths and limitations of the PCMH model, so as to continue to improve upon and promote it. Strengths of the model were evident to participants in this study; however, challenges were also described. It is important to note that these challenges are difficult to separate from wider healthcare system issues, including inadequate incentives for value-based care, and carry implications for PCMH and other models of healthcare delivery.
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Affiliation(s)
- Linda Weiss
- The New York Academy of Medicine, New York, NY, USA
| | | | - Meng Wu
- New York State Department of Health, Albany, NY, USA
| | | | - Foram Jasani
- The New York Academy of Medicine, New York, NY, USA
| | - José A Pagán
- NYU School of Global Public Health, New York, NY, USA
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Leung LB, Rose D, Guo R, Brayton CE, Rubenstein LV, Stockdale S. Mental health care integration and primary care patient experience in the Veterans Health Administration. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2021; 9:100587. [PMID: 34601395 PMCID: PMC11014737 DOI: 10.1016/j.hjdsi.2021.100587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Mental health specialists and care managers facilitate comprehensive care provision within medical homes. Despite implementation challenges, mental health integration is thought to improve patient-centered primary care. OBJECTIVES To examine the relationship between primary care patient experience and mental health integration. RESEARCH DESIGN Cross-sectional surveys from 168 primary care clinicians (PCPs) (n = 226) matched with assigned patients' surveys (n = 1734) in one Veterans Health Administration (VA) region, fiscal years 2012-2013. Multilevel regression models examined patient experience and mental health integration, adjusting for patient and PCP characteristics. MEASURES Patient experience outcomes were (1) experience with PCP and (2) receipt of comprehensive care, such as talked about "stress". Independent variables represented mental health integration- (1) PCP-rated communication with mental health and (2) proportion of clinic patients who saw integrated specialists. RESULTS 50% and 43% of patients rated their PCPs 10/10 and reported receiving comprehensive care, respectively. Neither patient experience or receipt of comprehensive care was significantly associated with PCP's ratings of communication with mental health, nor with proportion of clinic patients who saw integrated specialists. Among a subsample of patients who rated their mental health as poor/fair, however, we detected an association between proportion of clinic patients who saw integrated specialists and patient experience (odds ratio = 1.05, 95% confidence interval = 1.01-1.09, p = .01). CONCLUSIONS No association was observed between mental health integration and primary care patients' reported care experiences, but a significant association existed among patients who reported poor/fair mental health. More research is needed to understand patient experiences with regard to care model implementation.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Catherine E Brayton
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Wilson EK, Siegfried NR, Sorensen AV. Patients' and Caregivers' Experiences with the Multi-Payer Advanced Primary Care Practice Demonstration. J Gen Intern Med 2020; 35:3181-3187. [PMID: 32918203 PMCID: PMC7485592 DOI: 10.1007/s11606-020-06177-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 08/24/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) model aims to improve primary health care using a patient-centered approach. Little qualitative research has investigated how the PCMH model affects patient experience with care. OBJECTIVE To understand Medicaid and Medicare patient and caregiver experiences with PCMHs participating in the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration. DESIGN Qualitative study. PARTICIPANTS Medicare, Medicaid, and dually eligible patients who were patients in primary care practices participating in the MAPCP Demonstration and caregivers of such patients (N = 490). APPROACH From July through November 2014, a trained facilitator conducted 81 focus groups in the eight states participating in the MAPCP Demonstration. Separate groups were held for Medicare high-risk, Medicare low-risk, Medicaid, and dually eligible beneficiaries, their caregivers, and caregivers of Medicaid children (or, in Vermont, with patients participating in the Support and Services at Home program), in two different geographical areas in each state. Focus group discussions were recorded, transcribed, and analyzed using NVivo qualitative data analysis software. RESULTS Participants' experiences with care were generally consistent with the expectations of a PCMH, although some exceptions were noted. Medicaid only and dually eligible beneficiaries generally had less-positive experiences than Medicare beneficiaries. Most participants said their practices had not solicited feedback from them about their experiences with care. Few participants knew what the term "medical home" meant or were aware that their practices were working to become PCMHs, but many had noticed changes in recent years, primarily related to the conversion to electronic health records. CONCLUSIONS Most participants had positive experiences with their care. Opportunities exist, however, to improve care for Medicaid and dually eligible beneficiaries, and enhance patient awareness of and involvement in PCMH practice transformation.
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Goldberg DG, Gimm G, Burla SR, Nichols LM. Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home. Popul Health Manag 2019; 23:305-312. [PMID: 31816261 DOI: 10.1089/pop.2019.0189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient-provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.
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Affiliation(s)
- Debora Goetz Goldberg
- Department of Health Administration and Policy and George Mason University, Fairfax, Virginia, USA
| | - Gilbert Gimm
- Department of Health Administration and Policy and George Mason University, Fairfax, Virginia, USA
| | - Sriteja R Burla
- Department of Economics, George Mason University, Fairfax, Virginia, USA
| | - Len M Nichols
- Center for Health Policy Research and Ethics (CHPRE), George Mason University, Fairfax, Virginia, USA
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Aysola J, Schapira MM, Huo H, Werner RM. Organizational Processes and Patient Experiences in the Patient-centered Medical Home. Med Care 2018; 56:497-504. [PMID: 29629923 PMCID: PMC5945304 DOI: 10.1097/mlr.0000000000000910] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is increasing emphasis on the use of patient-reported experience data to assess practice performance, particularly in the setting of patient-centered medical homes. Yet we lack understanding of what organizational processes relate to patient experiences. OBJECTIVE Examine associations between organizational processes practices adopt to become PCMH and patient experiences with care. RESEARCH DESIGN We analyzed visit data from patients (n=8356) at adult primary care practices (n=22) in a large health system. We evaluated the associations between practice organizational processes and patient experience using generalized estimating equations (GEE) with an exchangeable correlation structure to account for patient clustering by practice in multivariate models, adjusting for several practice-level and patient-level characteristics. We evaluated if these associations varied by race/ethnicity, insurance type, and the degree of patient comorbidity MEASURES:: Predictors include overall PCMH adoption and adoption of six organizational processes: access and communications, patient tracking and registry, care management, test referral tracking, quality improvement and external coordination. Primary outcome was overall patient experience. RESULTS In our full sample, overall PCMH adoption score was not significantly associated with patient experience outcomes. However, among subpopulations with higher comorbidities, the overall PCMH adoption score was positively associated with overall patient experience measures [0.2 (0.06, 0.4); P=0.006]. Differences by race/ethnicity and insurance type in associations between specific organizational processes and patient experience were noted. CONCLUSION Although some organizational processes relate to patients' experiences with care irrespective of the background of the patient, further efforts are needed to align practice efforts with patient experience.
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Affiliation(s)
- Jaya Aysola
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Marilyn M. Schapira
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
- Crescenz VA Medical Center, Philadelphia PA
| | - Hairong Huo
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Rachel M. Werner
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
- Crescenz VA Medical Center, Philadelphia PA
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