Research & Academic Publishing
Given comprehensive data assets and a large network of practices and providers, Population Health is uniquely positioned to conduct original investigations and engage in research. Beyond using data to improve care delivery within our organization, we have also shared findings externally through academic publications. We are eager to inform policy and practice and to contribute to the growing evidence base for what works in population health.
2020 Academic Publications
- Richard E. Leiter, Charles T. Pu, Emanuele Mazzola, Julia Gallagher, Jennifer Wright, Shekinah Manigault, Susan T. Moore, Rachelle Bernacki,
Engaging Hospices in Quality Measurement and Improvement: Early Experiences of a Large Integrated Healthcare System,
Journal of Pain and Symptom Management,
2020, ISSN 0885-3924
- Brent Forester, Hannah Heintz, Gary Epstein-Lubow,
The Urgency to Implement Comprehensive, Chronic Disease Management Models of Dementia Care While Pursuing Further Evidence for Clinical Effectiveness and Health Care Cost Reduction,
The American Journal of Geriatric Psychiatry, Volume 28, Issue 3, 2020, Pages 337-338, ISSN 1064-7481
- Hannah Heintz, Patrick Monette, Gary Epstein-Lubow, Lorie Smith, Susan Rowlett, Brent P. Forester, Emerging Collaborative Care Models for Dementia Care in the Primary Care Setting: A Narrative Review, The American Journal of Geriatric Psychiatry, Volume 28, Issue 3, 2020, Pages 320-330, ISSN 1064-7481
- Pu, C.T., Pu, C.T., Gao, Y., Garrels, S., Vestal, M., Turner, M. and Vogeli, C., 2019. Evaluation of the Skilled Nursing Facility (SNF) Transitional Care Management Program (TCMP) Using Decision Support on Post-Acute Discharge SNF Length of Stay and Subsequent Hospital Readmissions. Journal of the American Medical Directors Association, 20(3), pp.B27-B28.
- Smith, M.A., Vaughan-Sarrazin, M.S., Yu, M., Wang, X., Nordby, P.A., Vogeli, C., Jaffery, J. and Metlay, J.P., 2019. The importance of health insurance claims data in creating learning health systems: evaluating care for high-need high-cost patients using the National Patient-Centered Clinical Research Network (PCORNet). Journal of the American Medical Informatics Association.
- Moura, L.M., Smith, J.R., Blacker, D., Vogeli, C., Schwamm, L.H. and Hsu, J., 2019. Medicare claims can identify post-stroke epilepsy. Epilepsy research, 151, pp.40-47.
- Moura, L.M., Smith, J.R., Blacker, D., Vogeli, C., Schwamm, L.H., Cole, A.J., Hernandez-Diaz, S. and Hsu, J., 2019. Epilepsy Among Elderly Medicare Beneficiaries. Medical care, 57(4), pp.318-324.
- Lakin, J.R., Robinson, M.G., Obermeyer, Z., Powers, B.W., Block, S.D., Cunningham, R., Tumblin, J.M., Vogeli, C. and Bernacki, R.E., 2019. Prioritizing Primary Care Patients for a Communication Intervention Using the “Surprise Question”: a Prospective Cohort Study. Journal of general internal medicine, pp.1-8.
- Obermeyer, Z., Powers, B., Vogeli, C. and Mullainathan, S., 2019. Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), pp.447-453.
- Lakin, J. R., Robinson, M. G., Obermeyer, Z., Powers, B. W., Block, S. D., Cunningham, R., … Bernacki, R. E. (2019). Prioritizing Primary Care Patients for a Communication Intervention Using the “Surprise Question”: a Prospective Cohort Study. Journal of General Internal Medicine, 34(8), 1467–1474. doi: 10.1007/s11606-019-05094-4
- Donelan, K., Barreto, E. A., Sossong, S., Michael, C., Estrada, J. J., Cohen, A. B., … & Schwamm, L. H. (2019). Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care, 25(1), 40-44.
- Neelam A. Phadke MD, Anna R. Wolfson MD, Christian Mancini BS, Xiaoqing Fu MS, Susan A. Goldstein MsIE, Jacqueline Ngo MPH, Jason H. Wasfy MD MPhil, Aidan Long MD, Aleena Banerji MD, Kimberly G. Blumenthal MD, MSc. Electronic Consultations in Allergy/Immunology. ScienceDirect. June 3, 2019.
- J.F. Greden, S.V. Parikh, A.J. Rothschild, M.E. Thase, B.W. Dunlop, C. DeBattista, C.R. Conway, B. P. Forester, F.M. Mondimore, R.C. Sheldon, M. Macaluso, J. Li, K. Brown, A. Gilbert, L. Burns, M.R. Jablonski, B. Dechairo. Impact of pharmacogenomics on clinical outcomes in major depressive disorder in the GUIDED trial: A large, patient- and rater-blinded, randomized, controlled study. PubMed. April, 2019.
- B.P. Forester, I. Vahia. Behavioral and Psychological Symptoms – An Emerging Crisis of the Alzheimer Dementia Epidemic. PubMed. March 1, 2019.
- C.T. Pu, MD, FACP, CMD, Y. Gao, S. Garrels, M. Vestal, M. Turner, RN, MS, CCM, C. Vogeli, PhD. Evaluation of the Skilled Nursing Facility (SNF) Transitional Care Management Program (TCMP) Using Decision Support on Post-Acute Discharge SNF Length of Stay and Subsequent Hospital Readmissions. JAMDA. March, 2019.
- Mallika L. Mendu, Salman Ahmed, Jason K. Maron, Sandhya K. Rao, Sreekanth K. Chaguturu, Megan F. May, Walter P. Mutter, Kelly A. Burdge, David J. R. Steele, David B. Mount, Sushrut S. Waikar, Jeffrey B. Weilburg and Thomas D. Sequist. Development of an electronic health record-based chronic kidney disease registry to promote population health management. BioMed Central. March 1, 2019.
- J.M. Wilkins, E.K. Goldstein, B.P. Forester. Characteristics of Hospice Referrals From an Inpatient Geriatric Psychiatry Unit. PubMed. February 27, 2019.
- Y.P. Kelly, S.S. Waikar, M. L. Mendu. When to stop renal replacement therapy in anticipation of renal recovery in AKI: The need for consensus guidelines. PubMed. January 1, 2019.
- I. Vahia, B.P. Forester. Motion Mapping in Humans as a Biomarker for Psychiatric Disorders. PubMed. January, 2019.
- Shah S.J., Schwamm L.H., Cohen A.B., Simoni M.R., Estrada J., Matiello M., Venkataramani A., Rao S.K. Virtual Visits Partially Replaced In-Person Visits In An ACO-Based Medical Specialty Practice. Health Affairs. Dec 2018.
- Yeung A.S., Trinh N.T., Chen J.A., Chang T.E., Stern T.A. Cultural Humility for Consultation-Liaison Psychiatrists. PubMed. Nov 2018.
- Curren L., Huz I., McKee M., Traeger L., Andres B.C., Chang T., Cassano P., Fava M., Alpert J., Yeung A., Gilman S.E., Trinh N. Patient Primary Language in a Culturally Focused Intervention for Latino Americans with Depression. PubMed. Nov 8, 2018.
- Chang T., Boyden S.D. Depression and Chronic Medical Illness: New Treatment Approaches. Springer Link. Oct 18, 2018.
- Mendu M.L., Michaelidis C.I., Chu M.C., Sahota J., Hauser L., Fay E., Smith A., Huether M.A., Dobija J., Yurkofsky M., Pu C.T., Britton K. Implementation of a skilled nursing facility readmission review process. PubMed. Jul 25, 2018.
- Hilty D.M., Rabinowitz T., McCarron R.M., Katzelnick D.J., Chang T., Bauer A.M., Fortney J. An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care. ScienceDirect. May 2018.
- Licurse A.M., Mehrotra A. The Effect of Telehealth on Spending: Thinking Through the Numbers. Annals of Internal Medicine. May 15, 2018.
- Cieslak K, Cather C., Maclaurin S., Wexler D., Thorndike A., Chang T., Pachas G., Vilme M., Freudenreich O., Evins A.E. Integrated Diabetes Management For Individuals With Serious Mental Illness. Schizophrenia Bulletin, Volume 44, Issue suppl. Apr 1, 2018, Pages S361–S362.
- Kelly N., Licurse A., Sperry K. The Benefits and Barriers to Remote Health Coaching in Patients at Risk for Cardiovascular Disease. AHA Journals. April 1, 2018.
- Mendu M.L., Ahmed S., Maron J.K., Rao S.K., Chaguturu S.K., May M. F., Mutter W.P., Burdge K.A., Steele D.J.R., Mount D.B., Waikar S.S., Weilburg J.B., Sequist T.D. Development of an electronic health record-based chronic kidney disease registry to promote population health management. BMC Nephrology. Mar 1, 2019.
- Levine D.M., Ouchi K., Blanchfield B., Diamond K., Licurse A., Pu C.T., Schnipper J.L. Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial. J Gen Intern Med. Feb 6, 2018.
- Kelly Y.P., Waikar S.S., Mendu M.L. When to stop renal replacement therapy in anticipation of renal recovery in AKI: The need for consensus guidelines. PubMed. Jan 28, 2018.
- Sepucha K., Atlas S.J., Chang Y., Dorrwachter J., Freiberg A., Mangla M., Rubash H.E., Simmons L.H., Cha T. Patient Decision Aids Improve Decision Quality and Patient Experience and Reduce SurgicalRates in Routine Orthopaedic Care: A Prospective Cohort Study. J Bone Joint Surg Am. 2017 August 2.
- Blumenthal K.J., Chang Y., Ferris T.G., Spirt J.C., Vogeli C., Wagle N., Metlay J.P. Using a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization. J Gen Intern Med. 2017 August 1.
- Lakin J.R., Koritsanszky L.A., Cunningham R., Maloney F.L., Neal B.J., Paladino J., Palmor M.C., Vogeli C., Ferris T.G., Block S.D., Gawande A.A., Bernacki R.E. A Systematic Intervention to Improve Serious Illness Communication in Primary Care. Health Aff. (Millwood). 2017 July 1.
- Hsu J., Price M., Vogeli C., Brand R., Chernew M.E., Chaguturu S.K., Weil E., Ferris T.G. Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO. Health Aff. (Millwood). 2017 May 1.
- Hsu J., Vogeli C., Price M., Brand R., Chernew M.E., Mohta N., Chaguturu S.K., Weil E., Ferris T.G. Substantial Physician Turnover And Beneficiary ‘Churn’ In A Large Medicare Pioneer ACO. Health Aff. (Millwood). 2017 April 1.
- Mendu M., Rao S., Waikar S. Conceptual Framework for Optimizing Care Across the CKD Spectrum. Am J Kidney Dis. 2017 Jan 23.
- Vogeli C, Spirt J, Brand R, Hsu J, Mohta N, Hong C, Weil E, Ferris TG. Implementing a Hybrid Approach to Select Patients for Care Management: Variations Across Practices. Am J Manag Care. 2016 May;22(5):358-365.
- Sepucha KR, Simmons LH, Barry MJ, Edgman-Levitan S, Licurse AM, Chaguturu Sk. Ten Years, Forty Decision Aids, and Thousands of Patient Uses: Shared Decision Making at Massachusetts General Hospital. Health Aff (Millwood) 2016 Apr 1;35(4):630-6.
- Colbert J, Ganguli I. To Identify Patients For Care Management Interventions, Look Beyond Big Data. Health Affairs Blog. April 19, 2016.
- Hsu J, Price M, Sprit J, Vogeli C, Brand R, Chernew ME, Chaguturu SK, Mohta N, Weil E, Ferris TG. Patient Population Loss at a Large Pioneer Accountable Care Organization and Implications for Refining The Program. Health Aff (Millwood). 2016 Mar 1;35(3):422-30.
- Haime V, Hong C, Mandel L, Mohta N, Iezzoni LI, Ferris TG, Vogeli C. Clinician considerations when selecting high-risk patients for care management. Am J Manag Care, 2015 Oct. 1
- Wasfy JH, Hidrue MK, Yeh RW, Armstrong K, Dec WG, Pomerantsev EV, Fifer MA, Ferris TG. Differences Among Cardiologists in Rates of Positive Coronary Angiograms. J Am Heart Assoc. Oct: 16, 2015
- Ganguli I, Wasfy JH, Ferris TG. “What Is the Right Number of Clinic Appointments?: Visit Frequency and the Accountable Care Organization.” JAMA, 2015 Apr 6.
- Hong CS, Atlas SJ, Ashburner JM, Chang Y, He W, Ferris TG, Grant RW. “Evaluating a Model to Predict Primary Care Physician-Defined Complexity in a Large Academic Primary Care Practice-Based Research Network.”J Gen Intern Med. 2015 Jun 6.
- Lage DE, Rusinak D, Carr D, Grabowski DC, Ackerly DC.” Creating a network of high-quality skilled nursing facilities: preliminary data on the post acute care quality improvement experiences of an accountable care organization.” J Am Geriatr Soc. 2015 Apr; 63(4):804-8.
- Mendu ML, Lundquist A, Aizer AA, Leaf DE, Robinson E, Steele DJ, Waikar SS. “The usefulness of diagnostic testing in the initial evaluation of chronic kidney disease.”JAMA Intern Med. 2015 May 1; 175(5):853-6.
- Powers BW, Chaguturu SK, Ferris TG.” Optimizing high-risk care management.” JAMA, 2015 Feb 24;313(8):795-6.
- Shih SL, Gerrard P, Goldstein R, Mix J, Ryan CM, Niewczyk P, Kazis L, Hefner J, Ackerly DC, Zafonte R, Schneider JC. “Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients.”J Gen Intern Med. 2015 May 9.
- Sistrom CL, Dreyer K, Weilburg JB, Perloff JN, Tompkins CP, Ferris TG. “Images of imaging: how to process and display imaging utilization for large populations.” AJR Am J Roentgenol. 2015 Apr; 204(4).
- Sistrom CL, Weilburg JB, Dreyer KJ, Ferris TG. “Provider Feedback about Imaging Appropriateness by Using Scores from Order Entry Decision Support: Raw Rates Misclassify Outliers.” Radiology. 2015 May; 275(2):469-79.
- Stein D, Chen C, Ackerly DC. “Disruptive innovation in academic medical centers: balancing accountable and academic care.”Acad Med. 2015 May; 90(5):594-8.
- Wasfy JH, Armstrong K, Milford CE, Sundt TM 3rd.” Doctors should share their uncertainty with patients and make decisions together.” Int J Cardiol. 2015 Mar 20; 187:109-110.
- Wu CA, Mulder AL, Zai AH, Hu Y, Costa M, Tishler LW, Saltzman JR, Ellner AL, Bitton A. “A population management system for improving colorectal cancer screening in a primary care setting.” J Eval Clin Pract. 2015 Aug 11.
- Sreekanth K. Chaguturu, Margaret Costello, David Connolly, Gary L. Gottlieb, and Timothy G. Ferris, Operational Lessons from a Large Accountable Care Organization. JCOM Journal. 2014 October. Vol. 21, No. 10
- Ackerly DC and Grabowski D, “Post-Acute Care Reform – Beyond the ACA,” N Engl J Med 2014; 370 (8): 689-691. 2014.
- Ackerly DC. Section Author/Editor for “Geriatric Primary Care.” In Meghan Kiefer and Curtis Chong (Ed.) Pocket Primary Care. 2014.
- Aizer AA, Paly JJ, Michaelson MD, Rao SK, Nguyen PL, Kaplan ID, Niemierko A, Olumi AF, Efstathiou JA. “Medical oncology consultation and minimization of overtreatment in men with low-risk prostate cancer.” J Oncol Pract. 2014 Mar; 10(2):107-12.
- Bhatia RS, Dudzinski DM, Malhotra R, Milford CE, Yoerger Sanborn DM, Picard MH, Weiner RB. “Educational Intervention to Reduce Outpatient Inappropriate Transthoracic Echocardiograms: A Randomized Control Trial.” JACC Cardiovasc Imaging. 2014. Sep7 (9): 857-66.
- Bhatia RS, Dudzinski DM, Milford CE, Picard MH, Weiner RB. “Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention“. Echocardiography. 2014 Sep; 31(8):916-23.
- Chen C, Ackerly DC, “Beyond ACOs and Bundled Payments: Medicare’s Shift Toward Accountability in Fee-for-Service,” JAMA 2014; 311(7): 673-674. 2014.
- Greenberg JO, Barnett ML,Spinks ML, Dudley JC, Frolkis JP. The “Medical Neighborhood” Integrating Primary and Specialty Care for Ambulatory Patients, JAMA, 2014 Mar;174(3):454-7
- Hong CS, Siegel AL, Ferris TG. “Caring for high-need, high-cost patients: what makes for a successful care management program?” Issue Brief (Common Fund). 2014 Aug;19:1-19.
- Ip IK, Gershanik EF, Schneider LI, Raja AS, Mar W, Seltzer S, Healey MJ, Khorasani R. “Impact of IT-Enabled Intervention on MRI Use for Back Pain”, American Journal of Medicine. 2014 Jun;127(6):512-8.
- Kadehjian EK, Schneider L, Greenberg JO, Dudley J, Kachalia A. “Challenges to implementing expanded team models: lessons from a centralised nurse-led cholesterol-lowering programme“. BMJ Qual Saf. 2014 Apr; 23(4):338-45.
- Mendu ML, Schneider LI, Aizer AA, Singh K, Leaf DE, Lee TH, Waikar SS. “Implementation of a CKD checklist for primary care providers.” Clin J Am Soc Nephrol. 2014 Sep 5;9(9):1526-35.
- Milford CE, Hutter, MM, Lillemoe KD, Ferris TG. “Optimizing Appropriate Use of Procedures in an Era of Payment Reform” Ann Surg. 2014 Aug;260(2):202-4.
- Powers BW, Chaguturu SK. “Employer health incentives: balancing consumerism and coordination.” Population Health Management. 2014 Jun;17(3):137-8.
- Rao, SK. “Utilization management in the changing health-care environment.” Clin Chim Acta. 2014 Jan 1; 427:109-10.
- Shinagare AB, Ip IK, Abbett SK, Hanson R, Seltzer SE, Khorasani R. “Inpatient imaging utilization: trends of the past decade.” AJR Am J Roentgenol. 2014 Mar; 202(3):W277-83.
- Wasfy JH, Rao SK, Chittle MD, Gallen KM, Isselbacher EM, Ferris TG. “Initial results of a cardiac e-consult pilot program.” J Am Coll Cardiol. 2014 Dec 23;64(24):2706-7.
- Ackerly DC, Chen C, Ferris TG, “How to Rehabilitate Medicare’s Post-Acute Services.” Harvard Business Review – Leading Health Care Innovation Series, October 25, 2013.
- Ackerly DC, Parekh A, Stein D, “A Framework for Career Pathways in Health Systems Improvement,” Academic Medicine 2013; 88(1): 56-60.
- Aizer AA, Paly JJ, Zietman AL, Nguyen PL, Beard CJ, Rao SK, Kaplan ID, Niemierko A, Hirsch MS, Wu CL, Olumi AF, Michaelson MD, D’Amico AV, Efstathiou JA. “Models of care and NCCN guideline adherence in very-low-risk prostate cancer.”J Natl Compr Canc Netw. 2013 Nov;11(11):1364-72.
- Bhatia RS, Milford CE, Picard MH, Weiner RB. “An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service.” JACC Cardiovasc Imaging. 2013 May; 6(5):545-55.
- Ip IK, Schneider L, Seltzer S, Smith A, Dudley J, A Menard, R Khorasani, “Impact of Provider-led, Technology-enabled Radiology Management Program on Imaging”, Am J Med, 2013 Aug;126(8):687-92
- Nabel, E., Ferris, TG, Slavin, P. “Balancing AMC’s Missions and Health Care Costs – Mission Impossible?” NEJM, 2013, 369;11.
- Torchiana DF, Colton DG, Rao SK, Lenz SK, Meyer GS, Ferris TG. “Massachusetts General Physicians Organization’s quality incentive program produces encouraging results.” Health Aff (Millwood). 2013 Oct;32(10):1748-56
- Aizer AA, Paly JJ, Zietman AL, Nguyen PL, Beard CJ, Rao SK, Kaplan ID, Niemierko A, Hirsch MS, Wu CL, Olumi AF, Michaelson MD, D’Amico AV, Efstathiou JA.” Multidisciplinary care and pursuit of active surveillance in low-risk prostate cancer.”J Clin Oncol. 2012 Sep 1st;30(25):3071-6.
- Choudhry NK, Saya UY, Shrank WH, Greenberg JO, Melia C, Bilodeau A, Kadehjian EK, Dolan ML, Dudley JC, Kachalia A. “Cost-related medication underuse: Prevalence among hospitalized managed care patients.” J Hosp Med 2012;7:104-109.
- Gandara, E, Moniz TT, Dolan ML, Melia C, Dudley J, Smith A, Kachalia A. “Improving adherence to treatment guidelines: a blueprint”, Crit Patw Cardio, 2009 Dec;8(4):139-45.
- Greenberg JO, Dudley JC, Ferris TG. “Engaging Specialists in Performance-Incentive Programs”, NEJM 2010; 362:1558-1560
- Licurse A, Kim MC, Dziura J, Forman HP, Formica RN, Makarov DV, Parikh CR, Gross CP. “Renal ultrasound in the evaluation of Acute Kidney Injury: developing a risk stratification framework“. JAMA Int Med, 2010.
- Milford, C., Ferris TG. A Modified “Golden Rule” for Health Care Organizations. Mayo Clin. Proc. 2012.
- Sommers BD, Desai N, Fiskio J, Licurse A, Thorndike M, Katz JT, Bates DW. An Educational Intervention to Improve Cost-Effective Care Among Medicine Housestaff: A Randomized Controlled Trial. Academic Medicine, 2012.