학술논문
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'학술논문'
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Esserman LJ, Thompson IM, Reid B, Nelson P, Ransohoff DF, Welch HG, HwangS , Berry DA, Kinzler KW, Black WC, Bissell M, Parnes H, Srivastava S . Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol. 2014 May;15(6):e234-42. doi: 10.1016/S1470-2045(13)70598-9.
Costantino JP, Gail MH, Pee D, AndersonS , Redmond CK, Benichou J, Wieand HS. Validation studies for models projecting the risk of invasive and total breast cancer incidence. J Natl Cancer Inst. 1999 Sep 15;91(18):1541-8. doi: 10.1093/jnci/91.18.1541.
Parmigiani G, Berry D, Aguilar O. Determining carrier probabilities for breast cancer-susceptibility genes BRCA1 and BRCA2. Am J Hum Genet. 1998 Jan;62(1):145-58. doi: 10.1086/301670.
Tyrer J, Duffy SW, Cuzick J. A breast cancer prediction model incorporating familial and personal risk factors. Stat Med. 2004 Apr 15;23(7):1111-30. doi: 10.1002/sim.1668.
Claus EB. Risk models used to counsel women for breast and ovarian cancer: a guide for clinicians. Fam Cancer. 2001;1(3-4):197-206. doi: 10.1023/a:1021135807900.
Ozanne EM, Annis C, Adduci K, Showstack J, Esserman L. Pilot trial of a computerized decision aid for breast cancer prevention. Breast J. 2007 Mar-Apr;13(2):147-54. doi: 10.1111/j.1524-4741.2007.00395.x.
Darabi H, Czene K, Zhao W, Liu J, Hall P, Humphreys K. Breast cancer risk prediction and individualised screening based on common genetic variation and breast density measurement. Breast Cancer Res. 2012 Feb 7;14(1):R25. doi: 10.1186/bcr3110.
Fergus KB, Ross KS, Scheuner MT, Blanco AM, Tice JA, Ziv E, Shieh Y, van 't Veer L, Olopade OI, Goodman DL, Tong BS, Harvey H, DeRosa D, Risty L, Silver E, Kaster A, Fiscalini AS, Blum K, Heise R, Sabacan L, Heditsian D, BrainS , Petruse A, Eklund M, Hiatt RA, Borowsky AD, Naeim A, Park HL, LaCroix AZ, Parker BA, Lancaster R, Esserman J, Wenger N, Arasu V, Anton-Culver H, Esserman LJ, Madlensky L. Germline Pathogenic Variants Among Women Without a History of Breast Cancer: A Secondary Analysis of the WISDOM Randomized Clinical Trial. JAMA Intern Med. 2025 Dec 12:e257323. doi: 10.1001/jamainternmed.2025.7323. Online ahead of print.
Esserman LJ, Fiscalini AS, Naeim A, Van't Veer LJ, Kaster A, Scheuner MT, LaCroix AZ, Borowsky AD, Anton-Culver H, Olopade OI, Esserman J, Lancaster R, Madlensky L, Blanco AM, Ross KS, Goodman DL, Tong BS, Hogarth M, Heditsian D, BrainS , Lee V, Blum K, Kim MO, Sabacan LP, Fergus KB, Yau C, Park HL, Parker BA, Kaplan C, Rhoads KF, Eder S , Adduci K, Matthews JB, Wenger NS, Shieh Y, Hiatt RA, Ziv E, Tice JA, Eklund M. Risk-Based vs Annual Breast Cancer Screening: The WISDOM Randomized Clinical Trial. JAMA. 2025 Dec 12:e2524784. doi: 10.1001/jama.2025.24784. Online ahead of print.
Fergus KB, Heise RS, Madlensky L, Fiscalini A, Sabacan L, TheinerS , Kapoor S , Soto IA, Blanco A, Ross K, Goodman-Gruen D, Scheuner M, Hu D, Heditsian D, Brain S , Arasu VA, Kaster A, Chapa L, Olopade OI, Eklund M, Tice JA, Ziv E, van 't Veer L, Esserman LJ, Shieh Y; Athena/WISDOM Network Collaborators and Advocate Partners. Integrating breast cancer polygenic risk scores at scale in the WISDOM Study: a national randomized personalized screening trial. Genome Med. 2025 Aug 28;17(1):97. doi: 10.1186/s13073-025-01524-7.
Leggat-Barr K, Ryu R, Hogarth M, Stover-Fiscalini A, Veer LV', Park HL, Lewis T, Thompson C, Borowsky A, Hiatt RA, LaCroix A, Parker B, Madlensky L, Naeim A, Esserman L. Early Ascertainment of Breast Cancer Diagnoses Comparing Self-Reported Questionnaires and Electronic Health Record Data Warehouse: The WISDOM Study. JCO Clin Cancer Inform. 2023 Aug;7:e2300019. doi: 10.1200/CCI.23.00019.
Esserman LJ, Thompson IM, Reid B, Nelson P, Ransohoff DF, Welch HG, Hwang
Costantino JP, Gail MH, Pee D, Anderson
Parmigiani G, Berry D, Aguilar O. Determining carrier probabilities for breast cancer-susceptibility genes BRCA1 and BRCA2. Am J Hum Genet. 1998 Jan;62(1):145-58. doi: 10.1086/301670.
Tyrer J, Duffy SW, Cuzick J. A breast cancer prediction model incorporating familial and personal risk factors. Stat Med. 2004 Apr 15;23(7):1111-30. doi: 10.1002/sim.1668.
Claus EB. Risk models used to counsel women for breast and ovarian cancer: a guide for clinicians. Fam Cancer. 2001;1(3-4):197-206. doi: 10.1023/a:1021135807900.
Ozanne EM, Annis C, Adduci K, Showstack J, Esserman L. Pilot trial of a computerized decision aid for breast cancer prevention. Breast J. 2007 Mar-Apr;13(2):147-54. doi: 10.1111/j.1524-4741.2007.00395.x.
Darabi H, Czene K, Zhao W, Liu J, Hall P, Humphreys K. Breast cancer risk prediction and individualised screening based on common genetic variation and breast density measurement. Breast Cancer Res. 2012 Feb 7;14(1):R25. doi: 10.1186/bcr3110.
Fergus KB, Ross KS, Scheuner MT, Blanco AM, Tice JA, Ziv E, Shieh Y, van 't Veer L, Olopade OI, Goodman DL, Tong BS, Harvey H, DeRosa D, Risty L, Silver E, Kaster A, Fiscalini AS, Blum K, Heise R, Sabacan L, Heditsian D, Brain
Esserman LJ, Fiscalini AS, Naeim A, Van't Veer LJ, Kaster A, Scheuner MT, LaCroix AZ, Borowsky AD, Anton-Culver H, Olopade OI, Esserman J, Lancaster R, Madlensky L, Blanco AM, Ross KS, Goodman DL, Tong BS, Hogarth M, Heditsian D, Brain
Fergus KB, Heise RS, Madlensky L, Fiscalini A, Sabacan L, Theiner
Leggat-Barr K, Ryu R, Hogarth M, Stover-Fiscalini A, Veer LV', Park HL, Lewis T, Thompson C, Borowsky A, Hiatt RA, LaCroix A, Parker B, Madlensky L, Naeim A, Esserman L. Early Ascertainment of Breast Cancer Diagnoses Comparing Self-Reported Questionnaires and Electronic Health Record Data Warehouse: The WISDOM Study. JCO Clin Cancer Inform. 2023 Aug;7:e2300019. doi: 10.1200/CCI.23.00019.
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Effectiveness of an Multi-Modal Intervention for Transitions of Care After Lower Limb Fracture
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Venkatesh KK, Chiang CW, Castillo WC, Battarbee AN, Donneyong M, Harper LM, Costantine M, Saade G, Werner EF, Boggess KA, Landon MB. Changing patterns in medication prescription for gestational diabetes during a time of guideline change in theUSA : a cross-sectional study. BJOG. 2022 Feb;129(3):473-483. doi: 10.1111/1471-0528.16960. Epub 2021 Nov 8.
Venkatesh KK, Wu J, Trinh A, CrossS , Rice D, Powe CE, Brindle S , Andreatta S , Bartholomew A, MacPherson C, Costantine MM, Saade G, McAlearney AS, Grobman WA, Landon MB. Patient Priorities, Decisional Comfort, and Satisfaction with Metformin versus Insulin for the Treatment of Gestational Diabetes Mellitus. Am J Perinatol. 2024 May;41(S 01):e3170-e3182. doi: 10.1055/s -0043-1777334. Epub 2023 Dec 4.
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Venkatesh KK, MacPherson C, Clifton RG, Powe CE, Bartholomew A, Gregory D, Trinh A, McAlearney AS, Fiechtner LG, Catalano P, Rice D, CrossS , Kutay H, Gabbe S , Grobman WA, Costantine MM, Battarbee AN, Boggess K, Katukuri V, Eichelberger K, Esakoff T, Feghali MN, Harper L, Kaimal A, Kole-White M, Mendez-Figueroa H, Mlynarczyk M, Sciscione A, Shook L, Sobhani NC, Stamilio DM, Werner E, Wiegand S , Zera CA, Zork NM, Saade G, Landon MB. Comparative effectiveness trial of metformin versus insulin for the treatment of gestational diabetes in the USA : clinical trial protocol for the multicentre DECIDE study. BMJ Open. 2024 Sep 24;14(9):e091176. doi: 10.1136/bmjopen-2024-091176.
Venkatesh KK, Chiang CW, Castillo WC, Battarbee AN, Donneyong M, Harper LM, Costantine M, Saade G, Werner EF, Boggess KA, Landon MB. Changing patterns in medication prescription for gestational diabetes during a time of guideline change in the
Venkatesh KK, Wu J, Trinh A, Cross
Venkatesh KK, Lynch CD, Powe CE, Costantine MM, Thung SF, Gabbe SG, Grobman WA, Landon MB. Risk of Adverse Pregnancy
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Connors, E.H., Stephan,
Weist, M.D., Sander, M.A., Walrath, C., Link, B., Nabors, L., Adelsheim,
Kutcher
Mcluckie A, Kutcher
Haine-Schlagel R, Roesch SC, Trask EV, Fawley-King K, Ganger WC, Aarons GA. The Parent Participation Engagement Measure (PPEM): Reliability and Validity in Child and Adolescent Community Mental Health Services. Adm Policy Ment Health. 2016 Sep;43(5):813-823. doi: 10.1007/s10488-015-0698-x.
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Abrishami, G.F. & Warren, J.
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Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE)
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Kearney SM, Williams K, Nikolajski C, Park MJ, Kraemer KL, Landsittel D, Kang C, Malito A, Schuster J. Stakeholder impact on the implementation of integrated care: Opportunities to consider forpatient -centered outcomes research . Contemp Clin Trials. 2021 Feb;101:106256. doi: 10.1016/j.cct.2020.106256. Epub 2020 Dec 29.
Williams K, MarkwardtS , Kearney SM, Karp JF, Kraemer KL, Park MJ, Freund P, Watson A, Schuster J, Beckjord E. Addressing Implementation Challenges to Digital Care Delivery for Adults With Multiple Chronic Conditions: Stakeholder Feedback in a Randomized Controlled Trial. JMIR Mhealth Uhealth. 2021 Feb 1;9(2):e23498. doi: 10.2196/23498.
Kearney SM, Williams K, Nikolajski C, Park MJ, Kraemer KL, Landsittel D, Kang C, Malito A, Schuster J. Stakeholder impact on the implementation of integrated care: Opportunities to consider for
Williams K, Markwardt
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Activating SilverSneakers Benefits for Seniors With Osteoarthritis: Proactive Versus Usual Care
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Evaluating Caregiver Involvement in Primary Care-Based Brief Interventions for Adolescent Alcohol Use Problems
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Brandeis University; Vanderbilt University Medical Center; Dartmouth-Hitchcock Medical Center; Indiana University; Patient-Centered Outcomes Research Institute
Supporting Practices In Respecting Elders Phase 1
Conwell LJ, Cohen JW. Characteristics of Persons with High Medical Expenditures in theU.S . Civilian Noninstitutionalized Population, 2002. Published online 2002:6.
Feder JL. Predictive modeling and team care for high-needpatients at HealthCare Partners. Health Aff (Millwood). 2011 Mar;30(3):416-8. doi: 10.1377/hlthaff.2011.0080. No abstract available.
Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. 2007 Dec;22 Suppl 3(Suppl 3):374-8. doi: 10.1007/s11606-007-0379-x.
Grant RW, Ashburner JM, Hong CS, Chang Y, Barry MJ, Atlas SJ. Definingpatient complexity from the primary care physician's perspective: a cohort study. Ann Intern Med. 2011 Dec 20;155(12):797-804. doi: 10.7326/0003-4819-155-12-201112200-00001.
High-Need, High-CostPatients : Who Are They and How Do They Use Health Care? | Commonwealth Fund. Accessed September 3, 2019. https://www.commonwealthfund.org/publications/issue-briefs/2016/aug/high-need-high-cost-patients -who-are-they-and-how-do-they-use
Shafir A, Garrigues SK, Schenker Y, Leff B, Neil J, Ritchie C. HomeboundPatient and Caregiver Perceptions of Quality of Care in Home-Based Primary Care: A Qualitative Study. J Am Geriatr Soc. 2016 Aug;64(8):1622-7. doi: 10.1111/jgs.14244. Epub 2016 Jul 7.
Sayer C. "Time Spent at Home" - APatient -Defined Outcome . NEJM Catalyst. Published online April 26, 2016. Accessed December 21, 2022. https://catalyst.nejm.org/doi/abs/10.1056/CAT.16.0854
McNabney MK, Green AR, Burke M, Le ST, Butler D, Chun AK, Elliott DP, Fulton AT, Hyer K, Setters B, Shega JW. Complexities of care: Common components of models of care in geriatrics. J Am Geriatr Soc. 2022 Jul;70(7):1960-1972. doi: 10.1111/jgs.17811. Epub 2022 Apr 29.
Auerbach DI, Levy DE, Maramaldi P, Dittus RS, Spetz J, Buerhaus PI, Donelan K. Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US. Health Aff (Millwood). 2021 Sep;40(9):1368-1376. doi: 10.1377/hlthaff.2021.00401.
Accountable Care Organizations (ACOs) | CMS. Accessed December 19, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO
Fraze TK, Beidler LB, Briggs ADM, Colla CH. Translating Evidence into Practice: ACOs' Use of Care Plans forPatients with Complex Health Needs. J Gen Intern Med. 2021 Jan;36(1):147-153. doi: 10.1007/s11606-020-06122-4. Epub 2020 Oct 1.
Ochieng N, Damico A, 2023. Medicare Advantage in 2023: Enrollment Update and Key Trends. KFF. Published August 9, 2023. Accessed August 17, 2023. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2023-enrollment-update-and-key-trends/
MLN6775421 - Medicare Wellness Visits. Accessed December 21, 2022. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html
Huang H, Zhu X, Wehby GL. Primary care physicians' participation in the Medicare shared savings program and preventive services delivery: Evidence from the first 7 years. Health Serv Res. 2022 Oct;57(5):1182-1190. doi: 10.1111/1475-6773.14030. Epub 2022 Jul 18.
Lind KE, Hildreth KL, Perraillon MC. Persistent Disparities in Medicare's Annual Wellness Visit Utilization. Med Care. 2019 Dec;57(12):984-989. doi: 10.1097/MLR.0000000000001229.
Beckman AL, Becerra AZ, Marcus A, DuBard CA, Lynch K, Maxson E, Mostashari F, King J. Medicare Annual Wellness Visit association with healthcare quality and costs. Am J Manag Care. 2019 Mar 1;25(3):e76-e82.
Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006 Jul;54(7):1136-41. doi: 10.1111/j.1532-5415.2006.00791.x.
Rodriguez,S , Munevar, D, Delaney, C, Yang, L, Tumlinson, A. Effective Management of High-Risk Medicare Populations. Published online September 2014.
Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009 Aug;57(8):1420-6. doi: 10.1111/j.1532-5415.2009.02383.x.
Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, Ricketts GD. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007 Dec 12;298(22):2623-33. doi: 10.1001/jama.298.22.2623.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998 Jan;36(1):8-27. doi: 10.1097/00005650-199801000-00004.
Boult C, Dowd B, McCaffrey D, Boult L, Hernandez R, Krulewitch H. Screening elders for risk of hospital admission. J Am Geriatr Soc. 1993 Aug;41(8):811-7. doi: 10.1111/j.1532-5415.1993.tb06175.x.
Travison TG, Pham E, Donelan K, Bartels SJ, Carter JA, Corelli K, Counsell SR, Crean M, Flaherty E, Michael C, Moran DS, Murff HJ, Perloff J, Ritchie CS. Assessing the feasibility, acceptability, and efficacy of a pragmatic pilot and full-scale trial to improve care for older adults with complex care needs: The SPIRE study. Contemp Clin Trials. 2025 Dec;159:108072. doi: 10.1016/j.cct.2025.108072. Epub 2025 Sep 2.
Conwell LJ, Cohen JW. Characteristics of Persons with High Medical Expenditures in the
Feder JL. Predictive modeling and team care for high-need
Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. 2007 Dec;22 Suppl 3(Suppl 3):374-8. doi: 10.1007/s11606-007-0379-x.
Grant RW, Ashburner JM, Hong CS, Chang Y, Barry MJ, Atlas SJ. Defining
High-Need, High-Cost
Shafir A, Garrigues SK, Schenker Y, Leff B, Neil J, Ritchie C. Homebound
Sayer C. "Time Spent at Home" - A
McNabney MK, Green AR, Burke M, Le ST, Butler D, Chun AK, Elliott DP, Fulton AT, Hyer K, Setters B, Shega JW. Complexities of care: Common components of models of care in geriatrics. J Am Geriatr Soc. 2022 Jul;70(7):1960-1972. doi: 10.1111/jgs.17811. Epub 2022 Apr 29.
Auerbach DI, Levy DE, Maramaldi P, Dittus RS, Spetz J, Buerhaus PI, Donelan K. Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US. Health Aff (Millwood). 2021 Sep;40(9):1368-1376. doi: 10.1377/hlthaff.2021.00401.
Accountable Care Organizations (ACOs) | CMS. Accessed December 19, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO
Fraze TK, Beidler LB, Briggs ADM, Colla CH. Translating Evidence into Practice: ACOs' Use of Care Plans for
Ochieng N, Damico A, 2023. Medicare Advantage in 2023: Enrollment Update and Key Trends. KFF. Published August 9, 2023. Accessed August 17, 2023. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2023-enrollment-update-and-key-trends/
MLN6775421 - Medicare Wellness Visits. Accessed December 21, 2022. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html
Huang H, Zhu X, Wehby GL. Primary care physicians' participation in the Medicare shared savings program and preventive services delivery: Evidence from the first 7 years. Health Serv Res. 2022 Oct;57(5):1182-1190. doi: 10.1111/1475-6773.14030. Epub 2022 Jul 18.
Lind KE, Hildreth KL, Perraillon MC. Persistent Disparities in Medicare'
Beckman AL, Becerra AZ, Marcus A, DuBard CA, Lynch K, Maxson E, Mostashari F, King J. Medicare Annual Wellness Visit association with healthcare quality and costs. Am J Manag Care. 2019 Mar 1;25(3):e76-e82.
Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006 Jul;54(7):1136-41. doi: 10.1111/j.1532-5415.2006.00791.x.
Rodriguez,
Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009 Aug;57(8):1420-6. doi: 10.1111/j.1532-5415.2009.02383.x.
Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, Ricketts GD. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007 Dec 12;298(22):2623-33. doi: 10.1001/jama.298.22.2623.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998 Jan;36(1):8-27. doi: 10.1097/00005650-199801000-00004.
Boult C, Dowd B, McCaffrey D, Boult L, Hernandez R, Krulewitch H. Screening elders for risk of hospital admission. J Am Geriatr Soc. 1993 Aug;41(8):811-7. doi: 10.1111/j.1532-5415.1993.tb06175.x.
Travison TG, Pham E, Donelan K, Bartels SJ, Carter JA, Corelli K, Counsell SR, Crean M, Flaherty E, Michael C, Moran DS, Murff HJ, Perloff J, Ritchie CS. Assessing the feasibility, acceptability, and efficacy of a pragmatic pilot and full-scale trial to improve care for older adults with complex care needs: The SPIRE study. Contemp Clin Trials. 2025 Dec;159:108072. doi: 10.1016/j.cct.2025.108072. Epub 2025 Sep 2.
Academic Journal
Report
Pragmatic Trial to Enhance Quality Safety, and Patient Experience in COPD
Report
Brandeis University; Indiana University School of Medicine; Dartmouth-Hitchcock Medical Center; Atrium Health Wake Forest Baptist; Griffin Hospital; Patient-Centered Outcomes Research Institute; Baylor Scott and White Health
Supporting Practices In Respecting Elders Phase 2
Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A Short Scale for Measuring Loneliness in Large Surveys: Results From Two Population-Based Studies. Res Aging. 2004;26(6):655-672. doi: 10.1177/0164027504268574.
Measuring hope: Development of the Herth Hope Index. Journal of Nursing Scholarship, 32, 309-315.
Singh GK. Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health. 2003 Jul;93(7):1137-43. doi: 10.2105/ajph.93.7.1137.
Kind AJ, JencksS , Brock J, Yu M, Bartels C, Ehlenbach W, Greenberg C, Smith M. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Ann Intern Med. 2014 Dec 2;161(11):765-74. doi: 10.7326/M13-2946.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998 Jan;36(1):8-27. doi: 10.1097/00005650-199801000-00004.
Practice Transformation. American Medical Association. Accessed December 21, 2022. https://www.ama-assn.org/practice-management/sustainability/practice-transformation
Maslach Burnout Inventory Manual, 4th Edition. ResearchGate. Accessed December 21, 2022. https://www.researchgate.net/project/Maslach-Burnout-Inventory-Manual-4th-Edition
Katzan IL, Lapin B. PROMIS GH (Patient -Reported Outcomes Measurement Information System Global Health) Scale in Stroke: A Validation Study. Stroke. 2018 Jan;49(1):147-154. doi: 10.1161/STROKEAHA.117.018766.
Thornton M, Travis SS. Analysis of the reliability of the modified caregiver strain index. J Gerontol B Psychol Sci Soc Sci. 2003 Mar;58(2):S127-32. doi: 10.1093/geronb/58.2.s127.
Fralick M, Bartsch E, Ritchie CS, Sacks CA. Estimating the Use of Potentially Inappropriate Medications Among Older Adults in theUnited States . J Am Geriatr Soc. 2020 Dec;68(12):2927-2930. doi: 10.1111/jgs.16779. Epub 2020 Aug 25.
Gupta A, Jin G, Reich A, Prigerson HG, Ladin K, Kim D, Ashana DC, Cooper Z, Halpern SD, Weissman JS. Association of Billed Advance Care Planning with End-of-Life Care Intensity for 2017 Medicare Decedents. J Am Geriatr Soc. 2020 Sep;68(9):1947-1953. doi: 10.1111/jgs.16683. Epub 2020 Aug 27.
Alexandre PK, HwangS , Roth KB, Gallo JJ, Eaton WW. COSTS OF DEPRESSION FROM CLAIMS DATA FOR MEDICARE RECIPIENTS IN A POPULATION-BASED SAMPLE. J Health Hum Serv Adm. 2016 Summer;39(1):72-94.
Subramaniam A, Ueno R, Tiruvoipati R, Darvall J, Srikanth V, Bailey M, Pilcher D, Bellomo R. Defining ICD-10 surrogate variables to estimate the modified frailty index: a Delphi-based approach. BMC Geriatr. 2022 May 13;22(1):422. doi: 10.1186/s12877-022-03063-x.
Trockel M, Bohman B, Lesure E, Hamidi MS, Welle D, Roberts L, Shanafelt T. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry. 2018 Feb;42(1):11-24. doi: 10.1007/s40596-017-0849-3. Epub 2017 Dec 1.
Hays RD, Bjorner JB, Revicki DA, Spritzer KL, Cella D. Development of physical and mental health summary scores from thepatient -reported outcomes measurement information system (PROMIS) global items. Qual Life Res. 2009 Sep;18(7):873-80. doi: 10.1007/s11136-009-9496-9. Epub 2009 Jun 19.
Living Independently with GRACE Commonwealth Fund. Accessed July 20, 2022. https://www.commonwealthfund.org/publications/case-study/2021/oct/living-independently- grace
Butler DE, Frank KI, Counsell SR. The GRACE Model. In: Malone ML, Capezuti EA, Palmer RM, eds. Geriatrics Models of Care: Bringing "Best Practice" to an Aging America. Springer International Publishing; 2015:125-138. doi:10.1007/978-3-319-16068-9_10
Gruber-Baldini AL, Velozo C, RomeroS , Shulman LM. Validation of the PROMIS(R) measures of self-efficacy for managing chronic conditions. Qual Life Res. 2017 Jul;26(7):1915-1924. doi: 10.1007/s11136-017-1527-3. Epub 2017 Feb 26.
PROMIS. Accessed July 20, 2022. https://www.healthmeasures.net/explore-measurement- systems/promis
Bickman L, Riemer M, Kelley SD, et al. Peabody Treatment Progress Battery PTPB 2010. Published online 2010:306
Scholle SH, Vuong O, Ding L, FryS , Gallagher P, Brown JA, Hays RD, Cleary PD. Development of and field test results for the CAHPS PCMH Survey. Med Care. 2012 Nov;50 Suppl(Suppl):S2-10. doi: 10.1097/MLR.0b013e3182610aba.
Hemming K, Kasza J, Hooper R, Forbes A, Taljaard M. A tutorial on sample size calculation for multiple-period cluster randomized parallel, cross-over and stepped-wedge trials using the Shiny CRT Calculator. Int J Epidemiol. 2020 Jun 1;49(3):979-995. doi: 10.1093/ije/dyz237.
Shiny CRT Calculator. https://clusterrcts.shinyapps.io/rshinyapp/
Accountable Care Organizations (ACOs) CMS. Accessed December 19, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO
Auerbach DI, Levy DE, Maramaldi P, Dittus RS, Spetz J, Buerhaus PI, Donelan K. Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US. Health Aff (Millwood). 2021 Sep;40(9):1368-1376. doi: 10.1377/hlthaff.2021.00401.
McNabney MK, Green AR, Burke M, Le ST, Butler D, Chun AK, Elliott DP, Fulton AT, Hyer K, Setters B, Shega JW. Complexities of care: Common components of models of care in geriatrics. J Am Geriatr Soc. 2022 Jul;70(7):1960-1972. doi: 10.1111/jgs.17811. Epub 2022 Apr 29.
High-Need, High-CostPatients : Who Are They and How Do They Use Health Care? Commonwealth Fund. Accessed September 3, 2019. https://www.commonwealthfund.org/publications/issue-briefs/2016/aug/high-need-high-cost-patients -who-are-they-and-how-do-they-use
Sayer C. "Time Spent at Home" - APatient -Defined Outcome . NEJM Catalyst. Published online April 26, 2016. Accessed December 21, 2022. https://catalyst.nejm.org/doi/abs/10.1056/CAT.16.0854
Shafir A, Garrigues SK, Schenker Y, Leff B, Neil J, Ritchie C. HomeboundPatient and Caregiver Perceptions of Quality of Care in Home-Based Primary Care: A Qualitative Study. J Am Geriatr Soc. 2016 Aug;64(8):1622-7. doi: 10.1111/jgs.14244. Epub 2016 Jul 7.
Grant RW, Ashburner JM, Hong CS, Chang Y, Barry MJ, Atlas SJ. Definingpatient complexity from the primary care physician's perspective: a cohort study. Ann Intern Med. 2011 Dec 20;155(12):797-804. doi: 10.7326/0003-4819-155-12-201112200-00001.
Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. 2007 Dec;22 Suppl 3(Suppl 3):374-8. doi: 10.1007/s11606-007-0379-x.
Feder JL. Predictive modeling and team care for high-needpatients at HealthCare Partners. Health Aff (Millwood). 2011 Mar;30(3):416-8. doi: 10.1377/hlthaff.2011.0080. No abstract available.
Conwell LJ, Cohen JW. Characteristics of Persons with High Medical Expenditures in theU.S . Civilian Noninstitutionalized Population, 2002. Published online 2002:6.
Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A Short Scale for Measuring Loneliness in Large Surveys: Results From Two Population-Based Studies. Res Aging. 2004;26(6):655-672. doi: 10.1177/0164027504268574.
Measuring hope: Development of the Herth Hope Index. Journal of Nursing Scholarship, 32, 309-315.
Singh GK. Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health. 2003 Jul;93(7):1137-43. doi: 10.2105/ajph.93.7.1137.
Kind AJ, Jencks
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998 Jan;36(1):8-27. doi: 10.1097/00005650-199801000-00004.
Practice Transformation. American Medical Association. Accessed December 21, 2022. https://www.ama-assn.org/practice-management/sustainability/practice-transformation
Maslach Burnout Inventory Manual, 4th Edition. ResearchGate. Accessed December 21, 2022. https://www.researchgate.net/project/Maslach-Burnout-Inventory-Manual-4th-Edition
Katzan IL, Lapin B. PROMIS GH (
Thornton M, Travis SS. Analysis of the reliability of the modified caregiver strain index. J Gerontol B Psychol Sci Soc Sci. 2003 Mar;58(2):S127-32. doi: 10.1093/geronb/58.2.s127.
Fralick M, Bartsch E, Ritchie CS, Sacks CA. Estimating the Use of Potentially Inappropriate Medications Among Older Adults in the
Gupta A, Jin G, Reich A, Prigerson HG, Ladin K, Kim D, Ashana DC, Cooper Z, Halpern SD, Weissman JS. Association of Billed Advance Care Planning with End-of-Life Care Intensity for 2017 Medicare Decedents. J Am Geriatr Soc. 2020 Sep;68(9):1947-1953. doi: 10.1111/jgs.16683. Epub 2020 Aug 27.
Alexandre PK, Hwang
Subramaniam A, Ueno R, Tiruvoipati R, Darvall J, Srikanth V, Bailey M, Pilcher D, Bellomo R. Defining ICD-10 surrogate variables to estimate the modified frailty index: a Delphi-based approach. BMC Geriatr. 2022 May 13;22(1):422. doi: 10.1186/s12877-022-03063-x.
Trockel M, Bohman B, Lesure E, Hamidi MS, Welle D, Roberts L, Shanafelt T. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry. 2018 Feb;42(1):11-24. doi: 10.1007/s40596-017-0849-3. Epub 2017 Dec 1.
Hays RD, Bjorner JB, Revicki DA, Spritzer KL, Cella D. Development of physical and mental health summary scores from the
Living Independently with GRACE Commonwealth Fund. Accessed July 20, 2022. https://www.commonwealthfund.org/publications/case-study/2021/oct/living-independently- grace
Butler DE, Frank KI, Counsell SR. The GRACE Model. In: Malone ML, Capezuti EA, Palmer RM, eds. Geriatrics Models of Care: Bringing "Best Practice" to an Aging America. Springer International Publishing; 2015:125-138. doi:10.1007/978-3-319-16068-9_10
Gruber-Baldini AL, Velozo C, Romero
PROMIS. Accessed July 20, 2022. https://www.healthmeasures.net/explore-measurement- systems/promis
Bickman L, Riemer M, Kelley SD, et al. Peabody Treatment Progress Battery PTPB 2010. Published online 2010:306
Scholle SH, Vuong O, Ding L, Fry
Hemming K, Kasza J, Hooper R, Forbes A, Taljaard M. A tutorial on sample size calculation for multiple-period cluster randomized parallel, cross-over and stepped-wedge trials using the Shiny CRT Calculator. Int J Epidemiol. 2020 Jun 1;49(3):979-995. doi: 10.1093/ije/dyz237.
Shiny CRT Calculator. https://clusterrcts.shinyapps.io/rshinyapp/
Accountable Care Organizations (ACOs) CMS. Accessed December 19, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO
Auerbach DI, Levy DE, Maramaldi P, Dittus RS, Spetz J, Buerhaus PI, Donelan K. Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US. Health Aff (Millwood). 2021 Sep;40(9):1368-1376. doi: 10.1377/hlthaff.2021.00401.
McNabney MK, Green AR, Burke M, Le ST, Butler D, Chun AK, Elliott DP, Fulton AT, Hyer K, Setters B, Shega JW. Complexities of care: Common components of models of care in geriatrics. J Am Geriatr Soc. 2022 Jul;70(7):1960-1972. doi: 10.1111/jgs.17811. Epub 2022 Apr 29.
High-Need, High-Cost
Sayer C. "Time Spent at Home" - A
Shafir A, Garrigues SK, Schenker Y, Leff B, Neil J, Ritchie C. Homebound
Grant RW, Ashburner JM, Hong CS, Chang Y, Barry MJ, Atlas SJ. Defining
Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. 2007 Dec;22 Suppl 3(Suppl 3):374-8. doi: 10.1007/s11606-007-0379-x.
Feder JL. Predictive modeling and team care for high-need
Conwell LJ, Cohen JW. Characteristics of Persons with High Medical Expenditures in the
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