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Prusaczyk B, Burke RE. It's time for the field of geriatrics to invest in implementation science. BMJ Qual Saf 2023; 32:700-703. [PMID: 37479476 DOI: 10.1136/bmjqs-2023-016263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Beth Prusaczyk
- Department of Medicine, Division of General Medical Sciences, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Institute for Informatics, Data Science, and Biostatistics, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Divisions of General Internal Medicine and Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Bushnell G, Lloyd J, Olfson M, Cook S, Das H, Crystal S. Antipsychotic Medication Use In Medicaid-Insured Children Decreased Substantially Between 2008 And 2016. Health Aff (Millwood) 2023; 42:973-980. [PMID: 37406239 PMCID: PMC10845053 DOI: 10.1377/hlthaff.2022.01625] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
After the rapid growth of pediatric antipsychotic prescribing in the early 2000s, especially in the Medicaid population, concerns regarding the safety and appropriateness of such prescribing increased. Many states implemented policy and educational initiatives aimed at safer and more judicious antipsychotic use. Antipsychotic use leveled off in the late 2000s, but there have been no recent national estimates of trends in antipsychotic use in children enrolled in Medicaid, and it is unclear how use varied by race and ethnicity. This study observed a sizable decline in antipsychotic use among children ages 2-17 between 2008 and 2016. Although the magnitude of change varied, declines were observed across foster care status, age, sex, and racial and ethnic groups studied. The proportion of children with an antipsychotic prescription who received any diagnosis associated with a pediatric indication that was approved by the Food and Drug Administration increased from 38 percent in 2008 to 45 percent in 2016, which may indicate a trend toward more judicious prescribing.
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Affiliation(s)
- Greta Bushnell
- Greta Bushnell , Rutgers University, New Brunswick, New Jersey
| | | | - Mark Olfson
- Mark Olfson, Columbia University and New York State Psychiatric Institute, New York, New York
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Kang-Yi CD, Page A. Purpose Formulation, Coalition Building, and Evidence Use in Public-Academic Partnerships: Web-Based Survey Study. JMIR Hum Factors 2022; 9:e29288. [PMID: 34989678 PMCID: PMC8771345 DOI: 10.2196/29288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/01/2021] [Accepted: 11/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Partnerships between academic institutions and public care agencies (public–academic partnerships [PAPs]) can promote effective policy making and care delivery. Public care agencies are often engaged in PAPs for evidence-informed policy making in health care. Previous research has reported essential partnership contextual factors and mechanisms that promote evidence-based policy making and practice in health care. However, the studies have not yet informed whether public care agency leaders’ and academic researchers’ perceptions of partnership purpose formulation and coalition building evolve through the PAP life cycle and whether public care agency leaders’ use of research evidence differs through life cycle stages. Objective This exploratory study aims to focus on PAPs designed to improve youth mental health and well-being outcomes. This study also aims to identify public care agency leaders’ and academic researchers’ perceptions of PAP purpose formulation (structure, goals, primary function, and agenda-setting process) and coalition building (mutual benefits, trust, convener’s role, member role clarity, and conflict management) by PAP life cycle stage and examine whether public care agency leaders’ use of research evidence differs according to the perception of PAP purpose formulation and coalition building through the PAP life cycle. Methods A web-based survey of PAP experience was conducted by recruiting academic researchers (n=40) and public care agency leaders (n=26) who were engaged in PAPs for the past 10 years. Public care agency leaders additionally participated in the survey of the Structured Interview for Evidence Use scale (n=48). Results Most public care agency leaders and academic researchers in PAPs formed, matured, and sustained perceived their PAP as having purpose formulation context well aligned with their organizational purpose formulation context, pursuing mutual benefits, having leadership representation and role clarity, having a higher level of trust, and knowing how to handle conflicts. Most PAPs across all life cycle stages crystallized another issue to focus, but not all PAPs with issue crystallization had purpose reformulation. Public care agency leaders who trusted academic researchers in their PAP had greater use of research evidence. Public care agency leaders in PAPs that had gone through new issue crystallization also showed greater use of research evidence compared with those that had not. Conclusions To promote public care agency leaders’ use of research evidence, focusing on developing trusting partnerships and continuously crystallizing PAP issues are important. International Registered Report Identifier (IRRID) RR2-10.2196/14382
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Affiliation(s)
- Christina D Kang-Yi
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Amy Page
- Graduate School of Social Service, Fordham University, New York City, NY, United States
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4
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Mackie TI, Kovacs KM, Simmel C, Crystal S, Neese-Todd S, Akincigil A. A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs. Health Serv Res 2020; 56:418-431. [PMID: 33369739 PMCID: PMC8143685 DOI: 10.1111/1475-6773.13610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective This article employs a best‐worst scaling (BWS) experiment to identify the claims‐based outcomes that matter most to patients and other relevant parties when evaluating pediatric antipsychotic monitoring programs in the United States. Data Sources Patients and relevant parties, with pediatric antipsychotic oversight and treatment experience, completed a BWS experiment, including policymakers (n = 31), foster care alumni (n = 28), caseworkers (n = 23), prescribing clinicians (n = 32), and caregivers (n = 18). Study Design Respondents received surveys with a scenario on antipsychotic monitoring programs and ranked 11 candidate claims‐based outcomes as most and least important for program evaluation. Data Analysis Stratified by respondent group, best‐worst scores were calculated to identify the relative importance of the claims‐based outcomes. A conditional logit examined whether candidate outcomes for safety, quality, and unintended consequences were preferred over reduction in antipsychotic treatment, the outcome used most often to evaluate antipsychotic monitoring programs. Principal Findings Safety indicators (eg, antipsychotic co‐pharmacy, cross‐class polypharmacy, higher than recommended doses) ranked among the top three candidate outcomes across respondent groups and were an important complement to antipsychotic treatment reduction. Foster care alumni prioritized “antipsychotic treatment reduction” and “increased psychosocial treatment.” Caseworkers, prescribers, and caregivers prioritized “increased follow‐up after treatment initiation.” Potential unintended consequences of an antipsychotic monitoring program ranked lowest, including increased use of other psychotropic medication classes (as a substitute), increased psychiatric hospital stays, and increased emergency room utilization. Results of the conditional logit model found only caregivers significantly preferred other indicators over antipsychotic treatment reduction, preferring improvements in follow‐up care (5.78) and psychosocial treatment (4.53) and reduction in prescriptions of higher than recommended doses (3.64). Conclusions The BWS experiment supported rank ordering of candidate claims‐based outcomes demonstrating the opportunity for future studies to align outcomes used in antipsychotic monitoring program evaluations with community preferences, specifically by diversifying metrics to include safety and quality indicators.
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Affiliation(s)
- Thomas I Mackie
- School of Public Health, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Katherine M Kovacs
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Cassandra Simmel
- School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Stephen Crystal
- School of Social Work, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Sheree Neese-Todd
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Ayse Akincigil
- School of Social Work, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
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5
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Keast SL, Tidmore LM, Shropshire D, Nesser N, Lambert TL. Characterization of Chronic Multiclass Psychotropic Polypharmacy and Psychotherapy in Foster Care Youth in a State Medicaid Population. J Manag Care Spec Pharm 2020; 25:1340-1348. [PMID: 31778625 PMCID: PMC10397855 DOI: 10.18553/jmcp.2019.25.12.1340] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Foster youth have higher rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy compared with nonfoster youth. However, less is known about the extent of multiclass psychotropic polypharmacy after adjusting for patient factors associated with psychotropic medication use OBJECTIVES: To (a) compare psychotropic medication use and psychotherapy use by youth in foster care to those not in foster care in the Oklahoma Medicaid population across various sociodemographic and clinical factors, and (b) determine if patient-related characteristics are associated with high levels of concurrent multiclass psychotropic polypharmacy. METHODS This cross-sectional, retrospective analysis was conducted using paid prescription, outpatient, and inpatient Oklahoma Medicaid administrative claims from calendar year 2016. Foster youth and adolescents aged 20 years or younger were identified (n = 9,325) and compared with the general Oklahoma Medicaid population of the same age (n = 639,868). Descriptive statistics highlight baseline demographic and clinical differences between the 2 groups. Multivariable logistic regression was used to determine if covariates were associated with concurrent multiclass psychotropic polypharmacy. A subgroup analysis of foster youth taking at least 1 psychotropic medication was also performed to determine factors associated with the highest level of concurrent multiclass psychotropic polypharmacy. RESULTS Foster care was associated with higher odds of concurrent multiclass psychotropic polypharmacy regardless of presence of psychotherapy. Among the subgroup of foster youth taking at least 1 psychotropic medication, attention deficit hyperactivity disorder medications were the most commonly prescribed medication class, followed by antidepressants and anxiolytics when use was not chronic. However, at the highest level of chronic multiclass psychotropic polypharmacy (4-5 chronic concurrent medications), antipsychotics rose to the top, and anxiolytics were the least likely to be prescribed. Overall, the foster care population had the highest proportion of individuals with concurrent multiclass psychotropic polypharmacy (9.2% vs. 1.9%, P < 0.0001). The highest level of chronic multiclass psychotropic polypharmacy was more likely to occur in males (OR = 1.66, 95% CI = 1.40-1.96) and patients living in group homes (OR = 4.13, 95% CI = 2.02-8.44) or foster homes (OR = 1.66, 95% CI = 1.25-2.19). Being overweight or obese was associated with an 83% higher odds of being at the highest level of concurrent multiclass psychotropic polypharmacy (95% CI = 1.27-2.64). CONCLUSIONS Despite higher psychotherapy use, high rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy in foster youth remain a concern for policymakers. Patterns observed at different levels of concurrent multiclass psychotropic polypharmacy may be key to identifying youth who require additional monitoring. Future research exploring factors associated with higher levels of psychotropic concurrent multiclass psychotropic polypharmacy in foster youth can lead to actionable interventions and important policy changes. DISCLOSURES This project was funded through the CHIP Health Services Initiative. Keast, Tidmore, and Lambert report contractual employment for the Oklahoma Health Care Authority. Nesser is an employee of the Oklahoma Health Care Authority, and Shropshire is an employee of the Oklahoma Department of Human Services. Keast discloses unrelated research grant funding from AbbVie, Amgen, Otsuka, and Purdue Pharma. Tidmore discloses unrelated research grant funding from Amgen and Otsuka. The remaining authors have no relevant disclosures or conflicts of interest to declare. Posters based on this study were presented at AMCP Nexus 2017; October 16-19, 2017; Grapevine, TX, and at the AMCP Annual Meeting 2018; April 23-26, 2018; Boston, MA.
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Affiliation(s)
- Shellie L Keast
- University of Oklahoma College of Pharmacy and Pharmacy Management Consultants, Oklahoma City, Oklahoma
| | - Laura M Tidmore
- University of Oklahoma College of Pharmacy and Pharmacy Management Consultants, Oklahoma City, Oklahoma
| | | | | | - Tammy L Lambert
- University of Oklahoma College of Pharmacy and Pharmacy Management Consultants, Oklahoma City, Oklahoma
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Kang-Yi CD. Optimizing the Impact of Public-Academic Partnerships in Fostering Policymakers' Use of Research Evidence: Proposal to Test a Conceptual Framework. JMIR Res Protoc 2019; 8:e14382. [PMID: 31127725 PMCID: PMC6555116 DOI: 10.2196/14382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 12/02/2022] Open
Abstract
Background Previous research has reported that public-academic partnerships (PAPs) can effectively promote PAP leaders’ use of research evidence in improving youth outcomes. However, the existing literature has not yet clarified whether and how PAP leaders’ use of research evidence evolves along the PAP life cycle and whether PAP partners’ concordant perceptions of usefulness of their PAP has an impact on PAP leaders’ use of research evidence. Developing a conceptual framework that recognizes the PAP life cycle and empirically identifying contexts and mechanisms of PAPs that promote PAP leaders’ use of research evidence from the PAP life cycle perspective are imperative to guide researchers and policymakers to successfully lead PAPs and foster policymakers’ use of research evidence for improving youth outcomes. Objective Utilizing an integrated framework of organizational life cycle perspective, a social partnership perspective, and a realist evaluation, this study examines the extent to which PAP development and PAP leaders’ use of research evidence can be characterized into life cycle stages and identifies PAP contexts and mechanisms that explain the progress of PAPs and PAP leaders’ use of research evidence through life cycle stages. Methods Recruiting PAPs across the United States that aim to improve mental health and promote well-being of youth aged 12-25 years, the study conducts a document analysis and an online survey of PAPs to inform policymakers and academic researchers on the contexts and mechanisms to increase PAP sustainability and promote policymakers’ use of research evidence in improving youth outcomes. Results Fifty-three PAPs that meet the recruitment criteria have been identified, and document review of PAPs and participant recruitment for the online survey of PAP experience have been conducted. Conclusions This paper will help policymakers and researchers gain a deeper knowledge of the contexts and mechanisms for each PAP life cycle stage in order to optimize PAP leaders’ use of research evidence in achieving positive youth outcomes. International Registered Report Identifier (IRRID) DERR1-10.2196/14382
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Affiliation(s)
- Christina D Kang-Yi
- Center for Mental Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
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Leckman-Westin E, Finnerty M, Scholle SH, Pritam R, Layman D, Kealey E, Byron S, Morden E, Bilder S, Neese-Todd S, Horwitz S, Hoagwood K, Crystal S. Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid. J Manag Care Spec Pharm 2018; 24:238-246. [PMID: 29485947 PMCID: PMC10397713 DOI: 10.18553/jmcp.2018.24.3.238] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines. OBJECTIVES To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use. METHODS Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring. RESULTS Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening. CONCLUSIONS While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children. DISCLOSURES This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.
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Affiliation(s)
- Emily Leckman-Westin
- 1 New York State Office of Mental Health, Albany, New York, and State University of New York at Albany, School of Public Health, Rensselaer, New York
| | - Molly Finnerty
- 2 New York State Office of Mental Health, and New York University Langone Health, New York, New York
| | | | - Riti Pritam
- 4 New York State Office of Mental Health, Albany, New York
| | - Deborah Layman
- 4 New York State Office of Mental Health, Albany, New York
| | - Edith Kealey
- 4 New York State Office of Mental Health, Albany, New York
| | - Sepheen Byron
- 3 National Committee for Quality Assurance, Washington, DC
| | - Emily Morden
- 3 National Committee for Quality Assurance, Washington, DC
| | | | | | - Sarah Horwitz
- 6 New York University Langone Health, New York, New York
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Hoagwood KE, Essock S, Morrissey J, Libby A, Donahue S, Druss B, Finnerty M, Frisman L, Narasimhan M, Stein BD, Wisdom J, Zerzan J. Use of Pooled State Administrative Data for Mental Health Services Research. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2017; 43:67-78. [PMID: 25578511 PMCID: PMC4500680 DOI: 10.1007/s10488-014-0620-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
State systems are a rich, albeit challenging, laboratory for policy-relevant services research studies. State mental health authorities routinely devote resources to collect data for state planning and reporting purposes. However, these data are rarely used in cross-state comparisons to inform state or federal policy development. In 2008, in response to key recommendations from the National Institute of Mental Health (NIMH) Advisory Council's "The Road Ahead: Research Partnership to Transform Services," (http://www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/reports/road-ahead.pdf), NIMH issued a request for applications (RFA) to support studies on the impact of state policy changes on access, cost, quality and outcomes of care for individuals with mental disorders. The purpose of the RFA was to bridge the divide between research and policy by encouraging research that used state administrative data across states, and to address significant state-defined health policy initiatives. Five projects involving eight states were selected through peer review for funding. Projects began in 2009 and were funded for 3 years. This report provides a brief description of the five projects, followed by an analysis of the impact, challenges, and lessons learned from these policy-partnered studies. We conclude by offering suggestions on ways to use state administrative data for informing state health policies, which is especially timely given national and state changes in the structure and financing of healthcare.
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Affiliation(s)
- Kimberly Eaton Hoagwood
- Department of Child and Adolescent Psychiatry, New York University Langone School of Medicine, New York, USA.
| | - Susan Essock
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University, New York, USA
| | - Joseph Morrissey
- Cecil G. Sheps Center for Health Services Research, Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Anne Libby
- School of Medicine, University of Colorado Health Sciences Center, Denver, USA
| | - Sheila Donahue
- New York State Office of Mental Health (OMH), Albany, USA
| | - Benjamin Druss
- Rollins School of Public Health, Emory University, Atlanta, USA
| | - Molly Finnerty
- New York State Office of Mental Health (OMH), Albany, USA.,Bureau of Evidence Based Services & Implementation Science, NYS Psychiatric Institute, New York, USA
| | - Linda Frisman
- School of Social Work, University of Connecticut, Storrs, USA
| | - Meera Narasimhan
- Department of Neuropsychiatry and Behavioral Sciences, School of Medicine, University of South Carolina, Columbia, USA
| | - Bradley D Stein
- RAND Corporation, School of Medicine, Pittsburgh, USA.,School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Jennifer Wisdom
- Office of the Vice President for Research, George Washington University, Washington, USA
| | - Judy Zerzan
- Colorado Department of Health Care Policy and Financing, Denver, USA
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