Clinical Focus

  • Internal Medicine
  • Primary Care

Academic Appointments

Administrative Appointments

  • Assistant Professor, Division of General Medical Disciplines, Department of Medicine, Stanford University (2015 - Present)
  • Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System (2011 - Present)
  • Instructor, Division of General Medical Disciplines, Department of Medicine, Stanford University (2011 - 2015)
  • Core Faculty, Clinical Excellence Research Center (2011 - 2014)

Honors & Awards

  • Career Development Award, VA Health Services Research & Development (2013-2018)
  • Milton W. Hamolsky Junior Faculty Scientific Presentation Award, Society for General Internal Medicine (2013)
  • Teaching Award for Division of General Medical Disciplines, Stanford University (2012)
  • Clinical Scholar, Robert Wood Johnson Foundation Clinical Scholars Program (2008-2011)
  • Member, Alpha Omega Alpha Honor Medical Society (2004)

Professional Education

  • Board Certification: Internal Medicine, American Board of Internal Medicine (2008)
  • Residency:University of Michigan School of Medicine (2008) MI
  • Medical Education:UCLA - School of Medicine (2005) CA
  • BA, Human Biology, Stanford University (2000)
  • MD, University of California, Los Angeles (2005)
  • MS, Health and Health Care Research; Robert Wood Johnson Clinical Scholars Program, University of Michigan (2010)

Research & Scholarship

Current Research and Scholarly Interests

Donna Zulman, MD, MS, is an assistant professor in the Division of General Medical Disciplines at Stanford University, and an investigator at the Center for Innovation to Implementation (Ci2i) in the VA Palo Alto Health Care System. Dr. Zulman received her MD from the University of California, Los Angeles. After completing a residency in Internal Medicine at the University of Michigan, she received a Masters in Health and Health Care Research through the Robert Wood Johnson Clinical Scholars Program at the University of Michigan and the Ann Arbor VA. Her research focuses on improving health care delivery for patients with multiple chronic conditions and complex medical and social needs, and optimizing health-related technology to personalize care and improve outcomes for high-risk patients. Dr. Zulman is currently supported by a VA Health Services Research & Development Career Development Award. Her research about patient-provider priority concordance and the inclusion of complex, older adults in clinical trials has been featured in The New York Times.


2014-15 Courses


All Publications

  • How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Jenchura, E. C., Cohen, D. M., Lewis, E. T., Houston, T. K., Asch, S. M. 2015; 30 (8): 1063-1070


    Patient eHealth technology offers potential support for disease self-management, but the value of existing applications for patients with multiple chronic conditions (MCCs) is unclear.To understand self-management and health care navigation challenges that patients face due to MCCs and to identify opportunities to support these patients through new and enhanced eHealth technology.After administering a screening survey, we conducted 10 focus groups of 3-8 patients grouped by age, sex, and common chronic conditions. Patients discussed challenges associated with having MCCs and their use of (and desires from) technology to support self-management. Three investigators used standard content analysis methods to code the focus group transcripts. Emergent themes were reviewed with all collaborators, and final themes and representative quotes were validated with a sample of participants.Fifty-three individuals with ≥3 chronic conditions and experience using technology for health-related purposes.Focus group participants had an average of five chronic conditions. Participants reported using technology most frequently to search for health information (96 %), communicate with health care providers (92 %), track medical information (83 %), track medications (77 %), and support decision-making about treatment (55 %). Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes.Although patients with multiple health issues use eHealth technology to support self-care for specific conditions, they also desire tools that transcend disease boundaries. By addressing the holistic needs of patients with MCCs, eHealth technology can advance health care from a disease-centered to a patient-centered model.

    View details for DOI 10.1007/s11606-015-3222-9

    View details for Web of Science ID 000358359400012

  • Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open Zulman, D. M., Pal Chee, C., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Ritchie, C., Asch, S. M. 2015; 5 (4)


    To investigate the relationship between multimorbidity and healthcare utilisation patterns among the highest cost patients in a large, integrated healthcare system.In this retrospective cross-sectional study of all patients in the U.S. Veterans Affairs (VA) Health Care System, we aggregated costs of individuals' outpatient and inpatient care, pharmacy services and VA-sponsored contract care received in 2010. We assessed chronic condition prevalence, multimorbidity as measured by comorbidity count, and multisystem multimorbidity (number of body systems affected by chronic conditions) among the 5% highest cost patients. Using multivariate regression, we examined the association between multimorbidity and healthcare utilisation and costs, adjusting for age, sex, race/ethnicity, marital status, homelessness and health insurance status.USA VA Health Care System.5.2 million VA patients.Annual total costs; absolute and share of costs generated through outpatient, inpatient, pharmacy and VA-sponsored contract care; number of visits to primary, specialty and mental healthcare; number of emergency department visits and hospitalisations.The 5% highest cost patients (n=261 699) accounted for 47% of total VA costs. Approximately two-thirds of these patients had chronic conditions affecting ≥3 body systems. Patients with cancer and schizophrenia were less likely to have documented comorbid conditions than other high-cost patients. Multimorbidity was generally associated with greater outpatient and inpatient utilisation. However, increased multisystem multimorbidity was associated with a higher outpatient share of total costs (1.6 percentage points per affected body system, p<0.01) but a lower inpatient share of total costs (-0.6 percentage points per affected body system, p<0.01).Multisystem multimorbidity is common among high-cost VA patients. While some patients might benefit from disease-specific programmes, for most patients with multimorbidity there is a need for interventions that coordinate and maximise efficiency of outpatient services across multiple conditions.

    View details for DOI 10.1136/bmjopen-2015-007771

    View details for PubMedID 25882486

  • Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT) JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Ezeji-Okoye, S. C., Shaw, J. G., Hummel, D. L., Holloway, K. S., Smither, S. F., Breland, J. Y., Chardos, J. F., Kirsh, S., Kahn, J. S., Asch, S. M. 2014; 29: S861-S869
  • Quality of Care for Patients with Multiple Chronic Conditions: The Role of Comorbidity Interrelatedness JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Asch, S. M., Martins, S. B., Kerr, E. A., Hoffman, B. B., Goldstein, M. K. 2014; 29 (3): 529-537


    Multimorbidity-the presence of multiple chronic conditions in a patient-has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.

    View details for DOI 10.1007/s11606-013-2616-9

    View details for Web of Science ID 000331962600025

  • Patient Interest in Sharing Personal Health Record Information A Web-Based Survey ANNALS OF INTERNAL MEDICINE Zulman, D. M., Nazi, K. M., Turvey, C. L., Wagner, T. H., Woods, S. S., An, L. C. 2011; 155 (12): 805-U46


    Electronic personal health record (PHR) systems are proliferating but largely have not realized their potential for enhancing communication among patients and their network of care providers.To explore preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR system, My HealtheVet.Web-based survey of a convenience sample.My HealtheVet Web site from 7 July through 4 October 2010.18 471 users of My HealtheVet.Interest in shared PHR access and preferences about who would receive access, the information that would be shared, and the activities that users would delegate.Survey respondents were predominantly men (92%) and aged 50 to 64 years (51%) or 65 years or older (39%); approximately 39% reported poor or fair health status. Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider). Among those who selected a family member other than a spouse or partner, 47% lived apart from the specified person. Preferences about degree of access varied on the basis of the type of information being shared, the type of activity being performed, and the respondent's relationship with the selected person.The survey completion rate was 40.8%. Results might not be generalizable to all My HealtheVet users.In a large survey of PHR users in the VA system, most respondents were interested in sharing access to their electronic health information with caregivers and non-VA providers. Existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their health care.Veterans Health Administration and The Robert Wood Johnson Foundation Clinical Scholars Program.

    View details for DOI 10.1059/0003-4819-155-12-201112200-00002

    View details for Web of Science ID 000298280500014

    View details for PubMedID 22184687

  • Examining the Evidence: A Systematic Review of the Inclusion and Analysis of Older Adults in Randomized Controlled Trials JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Sussman, J. B., Chen, X., Cigolle, C. T., Blaum, C. S., Hayward, R. A. 2011; 26 (7): 783-790


    Due to a shortage of studies focusing on older adults, clinicians and policy makers frequently rely on clinical trials of the general population to provide supportive evidence for treating complex, older patients.To examine the inclusion and analysis of complex, older adults in randomized controlled trials.A PubMed search identified phase III or IV randomized controlled trials published in 2007 in JAMA, NEJM, Lancet, Circulation, and BMJ. Therapeutic interventions that assessed major morbidity or mortality in adults were included. For each study, age eligibility, average age of study population, primary and secondary outcomes, exclusion criteria, and the frequency, characteristics, and methodology of age-specific subgroup analyses were reviewed.Of the 109 clinical trials reviewed in full, 22 (20.2%) excluded patients above a specified age. Almost half (45.6%) of the remaining trials excluded individuals using criteria that could disproportionately impact older adults. Only one in four trials (26.6%) examined outcomes that are considered highly relevant to older adults, such as health status or quality of life. Of the 42 (38.5%) trials that performed an age-specific subgroup analysis, fewer than half examined potential confounders of differential treatment effects by age, such as comorbidities or risk of primary outcome. Trials with age-specific subgroup analyses were more likely than those without to be multicenter trials (97.6% vs. 79.1%, p < 0.01) and funded by industry (83.3% vs. 62.7%, p < 0.05). Differential benefit by age was found in seven trials (16.7%).Clinical trial evidence guiding treatment of complex, older adults could be improved by eliminating upper age limits for study inclusion, by reducing the use of eligibility criteria that disproportionately affect multimorbid older patients, by evaluating outcomes that are highly relevant to older individuals, and by encouraging adherence to recommended analytic methods for evaluating differential treatment effects by age.

    View details for DOI 10.1007/s11606-010-1629-x

    View details for Web of Science ID 000291701200020

    View details for PubMedID 21286840

  • The Relative Merits of Population-Based and Targeted Prevention Strategies MILBANK QUARTERLY Zulman, D. M., Vijan, S., Omenn, G. S., Hayward, R. A. 2008; 86 (4): 557-580


    Preventive medicine has historically favored reducing a risk factor by a small amount in the entire population rather than by a large amount in high-risk individuals. The use of multivariable risk prediction tools, however, may affect the relative merits of this strategy.This study uses risk factor data from the National Health and Nutrition Examination Survey III to simulate a population of more than 100 million Americans aged thirty or older with no history of CV disease. Three strategies that could affect CV events, CV mortality, and quality-adjusted life years were examined: (1) a population-based strategy that treats all individuals with a low- or moderate-intensity intervention (in which the low-intensity intervention represents a public health campaign with no demonstrable adverse effects), (2) a targeted strategy that treats individuals in the top 25 percent based on a single risk factor (LDL), and (3) a risk-targeted strategy that treats individuals in the top 25 percent based on overall CV risk (as predicted by a multivariable prediction tool). The efficiency of each strategy was compared while varying the intervention's intensity and associated adverse effects, and the accuracy of the risk prediction tool.The LDL-targeted strategy and the low-intensity population-based strategy were comparable for CV events prevented over five years (0.79 million and 0.75 million, respectively), as were the risk-targeted strategy and moderate-intensity population-based strategy (1.56 million and 1.87 million, respectively). The risk-targeted strategy, however, was more efficient than the moderate-intensity population-based strategy (number needed to treat [NNT] 19 vs. 62). Incorporating a small degree of treatment-related adverse effects greatly magnified the relative advantages of the risk-targeted approach over other strategies. Reducing the accuracy of the prediction tool only modestly decreased this greater efficiency.A population-based prevention strategy can be an excellent option if an intervention has almost no adverse effects. But if the intervention has even a small degree of disutility, a targeted approach using multivariable risk prediction can prevent more morbidity and mortality while treating many fewer people.

    View details for DOI 10.1111/j.1468-0009.2008.00534.x

    View details for Web of Science ID 000261104300003

    View details for PubMedID 19120980

  • Association Between Acute Medical Exacerbations and Consuming or Producing Web-Based Health Information: Analysis From Pew Survey Data JOURNAL OF MEDICAL INTERNET RESEARCH Gidwani, R., Zulman, D. 2015; 17 (6)


    The Internet is an increasingly important resource for individuals who seek information from both health professionals and peers. While the demographic and health characteristics of persons who use health information technology has been well described, less is known about the relationship between these health characteristics and level of engagement with health information technology. Even less is known about whether persons who produce Web-based health information differ in health status from persons who consume such content.We explored the health characteristics of persons who engage with the Internet for the purposes of consuming or producing Web-based health information, and specifically, whether healthier versus sicker persons engage with health information technology in different ways.We analyzed data from the 2012 Pew Health survey, a landline and cell phone survey of 3104 adults in the United States. Using multiple logistic regression with sampling weights, we examined the association between sociodemographic and health characteristics and the consumption or production of Web-based health information. Sociodemographic variables included age, sex, race, and education. Health characteristics included self-reported health status, presence of chronic condition(s), and having an acute medical exacerbation. Acute medical exacerbations were defined as an emergency department visit, hospitalization, or other serious medical emergency in the last 12 months.The majority of the sample reported good or excellent health (79.7%), although 50.3% reported having at least one chronic condition. About a fifth (20.2%) of the sample experienced an acute medical exacerbation in the past year. Education was the sociodemographic characteristic most strongly associated with consuming Web-based health information. The strongest health-related predictors of consuming Web-based health information were an acute medical exacerbation (OR 2.39, P<.001) and having a chronic condition (OR 1.54, P=.007). Having an acute medical exacerbation was the only predictor of producing Web-based health information (OR 1.97, P=.003). All participants, regardless of health status, were most interested in Web-based health information regarding diseases or medical problems. However, persons with acute medical exacerbations were more likely to seek Web-based health information regarding medical tests, procedures, and drugs compared to persons without acute medical exacerbations.Producers of Web-based health information differ from consumers of this information in important health characteristics that could skew the content of peer-generated Web-based health information and overrepresent the experiences of persons with acute medical exacerbations. Providers may have a role to play in directing patients towards high-quality, easy-to-understand online information, especially information regarding treatments and procedures.

    View details for DOI 10.2196/jmir.3801

    View details for Web of Science ID 000356819800012

    View details for PubMedID 26104000

  • The Effect of Medical Comorbidities on Male and Female Veterans' Use of Psychotherapy for PTSD. Medical care Breland, J. Y., Greenbaum, M. A., Zulman, D. M., Rosen, C. S. 2015; 53 (4): S120-7


    Posttraumatic stress disorder (PTSD) is associated with an increased risk for medical comorbidities that may prevent participation in psychotherapy. The present study investigated whether medical comorbidities were associated with lower initiation rates and fewer psychotherapy visits for PTSD. Because women are more likely to initiate psychotherapy after traumatic events, we also assessed whether relationships were weaker among women.Veterans (N=482, 47% women) recently diagnosed with PTSD completed a survey assessing demographics, mood, functional status, and interest in treatment. Data on medical comorbidities, psychotherapy visits, antidepressant prescriptions, and service connection were assessed longitudinally through administrative files. Logistic and negative binomial regressions assessed associations between number of medical comorbidities in the 2 years before the survey and the initiation and number of psychotherapy visits for PTSD in the year after the survey. All analyses were stratified by sex and controlled for survey and administrative variables.The relationship between medical comorbidities and number of psychotherapy visits was stronger among women than among men. A greater number of medical comorbidities was associated with significantly fewer psychotherapy visits in the total sample [incidence rate ratio: 0.91; 95% confidence interval (CI): 0.83, 1.00] and among women (incidence rate ratio: 0.87; 95% CI: 0.77, 0.99), but not among men (95% CI: 0.75, 1.01). Medical comorbidities were not associated with the initiation of psychotherapy among men or women.Addressing medical comorbidities may help individuals remain in psychotherapy for PTSD. Medical comorbidities may play a larger role in the number of psychotherapy visits among women than men.

    View details for DOI 10.1097/MLR.0000000000000284

    View details for PubMedID 25767965

  • Blue Button use by patients to access and share health record information using the Department of Veterans Affairs' online patient portal JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Turvey, C., Klein, D., Fix, G., Hogan, T. P., Woods, S., Simon, S. R., Charlton, M., Vaughan-Sarrazin, M., Zulman, D. M., Dindo, L., Wakefield, B., Graham, G., Nazi, K. 2014; 21 (4): 657-663


    The Blue Button feature of online patient portals promotes patient engagement by allowing patients to easily download their personal health information. This study examines the adoption and use of the Blue Button feature in the Department of Veterans Affairs' (VA) personal health record portal, My HealtheVet.An online survey presented to a 4% random sample of My HealtheVet users between March and May 2012. Questions were designed to determine characteristics associated with Blue Button use, perceived value of use, and how Veterans with non-VA providers use the Blue Button to share information with their non-VA providers.Of the survey participants (N=18 398), 33% were current Blue Button users. The most highly endorsed benefit was that it helped patients understand their health history better because all the information was in one place (73%). Twenty-one percent of Blue Button users with a non-VA provider shared their VA health information, and 87% reported that the non-VA provider found the information somewhat or very helpful. Veterans' self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. When comparing Blue Button users and non-users, barriers to adoption were low awareness of the feature and difficulty using the Blue Button.This study contributes to the understanding of early Blue Button adoption and use of this feature for patient-initiated sharing of health information. Educational efforts are needed to raise awareness of the Blue Button and to address usability issues that hinder adoption.

    View details for DOI 10.1136/amiajnl-2014-002723

    View details for Web of Science ID 000337660600018

    View details for PubMedID 24740865

  • Costs Associated With Multimorbidity Among VA Patients MEDICAL CARE Yoon, J., Zulman, D., Scott, J. Y., Maciejewski, M. L. 2014; 52 (3): S31-S36


    Multimorbidity (the presence of multiple chronic conditions) is associated with high levels of healthcare utilization and associated costs. We investigated the association between number of chronic conditions and costs of care for nonelderly and elderly Veterans Affairs (VA) patients, and estimated mean VA healthcare costs for the most prevalent and most costly combinations of 3 conditions (triads).We identified a cohort of 5,233,994 patients who received care within the VA system in fiscal year 2010. We estimated the costs of VA care for each patient using established methods and aggregated costs for inpatient care, outpatient care, prescription drugs, and contract care. Using ICD-9 diagnosis fields from all inpatient and outpatient records, we determined the prevalence of 28 chronic conditions and all condition triads. We then compared the condition-cost gradient, most prevalent triads, and most costly triads among nonelderly (below 65 y) and elderly (65 y and above) patients.Almost one third of nonelderly and slightly more than a third of elderly VA patients had ≥3 conditions, but these patients accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both nonelderly and elderly patients was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions that were present in the most costly triads included spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. Although patients with the most costly triads had average costs that were 3 times higher than average costs among patients with ≥3 conditions, the prevalence of these costly triads was extremely low (0.1%-0.4%).Patients with multiple chronic conditions account for a disproportionate share of VA healthcare expenditures. Interventions that aim to optimize care and contain costs for multimorbid patients need to incorporate strategies specific to the most prevalent and the most costly combinations of conditions.

    View details for Web of Science ID 000337926100006

    View details for PubMedID 24561756

  • Implementation and evaluation of an incentivized Internet-mediated walking program for obese adults TRANSLATIONAL BEHAVIORAL MEDICINE Zulman, D. M., Damschroder, L. J., Smith, R. G., Resnick, P. J., Sen, A., Krupka, E. L., Richardson, C. R. 2013; 3 (4): 357-369


    In response to rising health care costs associated with obesity rates, some health care insurers are adopting incentivized technology-enhanced wellness programs. The purpose of this study is to evaluate the large-scale implementation of an incentivized Internet-mediated walking program for obese adults and to examine program acceptance, adherence, and impact. A mixed-methods evaluation was conducted to investigate program implementation, acceptance, and adherence rates, and physical activity rates among program participants. Program implementation was shaped by national and state policies, data security concerns, and challenges related to incentivizing participation. Among 15,397 eligible individuals, 6,548 (43 %) elected to participate in the walking program, achieving an average of 6,523 steps/day (SD 2,610 steps). Participants who uploaded step counts for 75 % of days for a full year (n = 2,885) achieved an average of 7,500 steps (SD 3,093). Acceptance and participation rates in this incentivized Internet-mediated walking program suggest that such interventions hold promise for engaging obese adults in physical activity.

    View details for DOI 10.1007/s13142-013-0211-6

    View details for Web of Science ID 000209413000005

  • Research Priorities in Geriatric Palliative Care: Multimorbidity JOURNAL OF PALLIATIVE MEDICINE Ritchie, C. S., Zulman, D. M. 2013; 16 (8): 843-847


    Abstract With global aging and scientific advances extending survival, the number of adults experiencing multiple chronic conditions has grown substantially and is projected to increase by another third between 2000 and 2030. Among the many challenges posed by multimorbidity, some of the most pressing include how to characterize and measure comorbid conditions, understand symptoms and illness burden, and provide person-centered care in the context of competing health care priorities and increasing complexity. In this white paper emanating from a National Institute on Aging supported conference to discuss research gaps at the geriatrics-palliative care interface, the authors review common definitions of multimorbidity; describe the association between multimorbidity and quality of life, functional status, quality of care, and health care utilization; note content and methodological gaps in multimorbidity evidence; and make recommendations regarding research priorities in this area of expanding public health impact.

    View details for DOI 10.1089/jpm.2013.9491

    View details for Web of Science ID 000322114600012

    View details for PubMedID 23777331

  • Facilitating Out-of-Home Caregiving Through Health Information Technology: Survey of Informal Caregivers' Current Practices, Interests, and Perceived Barriers JOURNAL OF MEDICAL INTERNET RESEARCH Zulman, D. M., Piette, J. D., Jenchura, E. C., Asch, S. M., Rosland, A. 2013; 15 (7): 252-263


    Many patients with chronic conditions are supported by out-of-home informal caregivers-family members, friends, and other individuals who provide care and support without pay-who, if armed with effective consumer health information technology, could inexpensively facilitate their care.We sought to understand caregivers' use of, interest in, and perceived barriers to health information technology for out-of-home caregiving.We conducted 2 sequential Web-based surveys with a national sample of individuals who provide out-of-home caregiving to an adult family member or friend with a chronic illness. We queried respondents about their use of health information technology for out-of-home caregiving and used multivariable regression to investigate caregiver and care-recipient characteristics associated with caregivers' technology use for caregiving.Among 316 out-of-home caregiver respondents, 34.5% (109/316) reported using health information technology for caregiving activities. The likelihood of a caregiver using technology increased significantly with intensity of caregiving (as measured by number of out-of-home caregiving activities). Compared with very low intensity caregivers, the adjusted odds ratio (OR) of technology use was 1.88 (95% CI 1.01-3.50) for low intensity caregivers, 2.39 (95% CI 1.11-5.15) for moderate intensity caregivers, and 3.70 (95% CI 1.62-8.45) for high intensity caregivers. Over 70% (149/207) of technology nonusers reported interest in using technology in the future to support caregiving. The most commonly cited barriers to technology use for caregiving were health system privacy rules that restrict access to care-recipients' health information and lack of familiarity with programs or websites that facilitate out-of-home caregiving.Health information technology use for out-of-home caregiving is common, especially among individuals who provide more intense caregiving. Health care systems can address the mismatch between caregivers' interest in and use of technology by modifying privacy policies that impede information exchange.

    View details for DOI 10.2196/jmir.2472

    View details for Web of Science ID 000324620300019

    View details for PubMedID 23841987

  • Cardiac Risk Is Not Associated With Hypertension Treatment Intensification AMERICAN JOURNAL OF MANAGED CARE Sussman, J. B., Zulman, D. M., Hayward, R., Hofer, T. P., Kerr, E. A. 2012; 18 (8): 414-420


    Considering cardiovascular (CV) risk could make clinical care more efficient and individualized, but most practice guidelines focus on single risk factors. We sought to determine if hypertension treatment intensification (TI) is more likely in patients with elevated CV risk.Prospective cohort study of 856 US veterans with diabetes and elevated blood pressure (BP).We used multilevel logistic regression to compare TI across 3 CV risk groups: those with history of heart disease, a high-risk primary prevention group (10-year event risk >20% but no history of heart disease), and those with low/ medium CV risk (10-year event risk <20%).There were no significant differences in TI rates across risk groups, with adjusted odds ratios (ORs) of 1.19 (95% confidence interval 0.77-1.84) and 1.18 (0.76-1.83) for high-risk patients and those with a history of CVD, respectively, compared with those of low/medium risk. Several individual risk factors were associated with higher rates of TI: systolic BP, mean BP in the prior year, and higher glycated hemoglobin. Self-reported home BP <140/90 mm Hg was associated with lower rates of TI. Incorporating CV risk into TI decision algorithms could prevent an estimated 38% more cardiac events without increasing the number of treated patients.While an individual's BP alters clinical decisions about TI, overall CV risk does not appear to play a role in clinical decision making. Adoption of TI decision algorithms that incorporate CV risk could substantially enhance the efficiency and clinical utility of CV preventive care.

    View details for Web of Science ID 000309036300002

    View details for PubMedID 22928756

  • Access to the Medical Record ANNALS OF INTERNAL MEDICINE Zulman, D. M., Nazi, K. M., Asch, S. M., Wagner, T. H. 2012; 156 (9): 668-668
  • The influence of diabetes psychosocial attributes and self-management practices on change in diabetes status PATIENT EDUCATION AND COUNSELING Zulman, D. M., Rosland, A., Choi, H., Langa, K. M., Heisler, M. 2012; 87 (1): 74-80


    To examine the influence of diabetes psychosocial attributes and self-management on glycemic control and diabetes status change.Using data from the Health and Retirement Study, a nationally representative longitudinal study of U.S. adults >51 years, we examined cross-sectional relationships among diabetes psychosocial attributes (self-efficacy, risk awareness, care understanding, prioritization of diabetes, and emotional distress), self-management ratings, and glycemic control. We then explored whether self-management ratings and psychosocial attributes in 2003 predicted change in diabetes status in 2004.In multivariate analyses (N=1834), all diabetes psychosocial attributes were associated with self-management ratings, with self-efficacy and diabetes distress having the strongest relationships (adj coeff=8.1, p<0.01 and -4.1, p<0.01, respectively). Lower self-management ratings in 2003 were associated cross-sectionally with higher hemoglobin A1C (adj coeff=0.16, p<0.01), and with perceived worsening diabetes status in 2004 (adj OR=1.36, p<0.05), with much of this latter relationship explained by diabetes distress.Psychosocial attributes, most notably diabetes-related emotional distress, contribute to difficulty with diabetes self-management, poor glycemic control, and worsening diabetes status over time.Self-management and adherence interventions should target psychosocial attributes such as disease-related emotional distress.

    View details for DOI 10.1016/j.pec.2011.07.013

    View details for Web of Science ID 000303182000013

    View details for PubMedID 21840149

  • Transfer of Information from Personal Health Records: A Survey of Veterans Using My HealtheVet TELEMEDICINE AND E-HEALTH Turvey, C. L., Zulman, D. M., Nazi, K. M., Wakefield, B. J., Woods, S. S., Hogan, T. P., Weaver, F. M., McInnes, K. 2012; 18 (2): 109-114


    Personal health records provide patients with ownership of their health information and allow them to share information with multiple healthcare providers. However, the usefulness of these records relies on patients understanding and using their records appropriately. My HealtheVet is a Web-based patient portal containing a personal health record administered by the Veterans Health Administration. The goal of this study was to explore veterans' interest and use of My HealtheVet to transfer and share information as well as to identify opportunities to increase veteran use of the My HealtheVet functions.Two waves of data were collected in 2010 through an American Customer Satisfaction Index Web-based survey. A random sample of veterans using My HealtheVet was invited to participate in the survey conducted on the My HealtheVet portal through a Web-based pop-up browser window.Wave One results (n=25,898) found that 41% of veterans reported printing information, 21% reported saving information electronically, and only 4% ever sent information from My HealtheVet to another person. In Wave Two (n=18,471), 30% reported self-entering medication information, with 18% sharing this information with their Veterans Affairs (VA) provider and 9.6% sharing with their non-VA provider.Although veterans are transferring important medical information from their personal health records, increased education and awareness are needed to increase use. Personal health records have the potential to improve continuity of care. However, more research is needed on both the barriers to adoption as well as the actual impact on patient health outcomes and well-being.

    View details for DOI 10.1089/tmj.2011.0109

    View details for Web of Science ID 000301041200006

    View details for PubMedID 22304439

  • Adapting an in-person patient-caregiver communication intervention to a tailored web-based format PSYCHO-ONCOLOGY Zulman, D. M., Schafenacker, A., Barr, K. L., Moore, I. T., Fisher, J., McCurdy, K., Derry, H. A., Saunders, E. W., An, L. C., Northouse, L. 2012; 21 (3): 336-341


    Interventions that target cancer patients and their caregivers have been shown to improve patient-caregiver communication, support, and emotional well-being.To adapt an in-person communication intervention for cancer patients and caregivers to a web-based format, and to examine the usability and acceptability of the web-based program among representative users.A tailored, interactive web-based communication program for cancer patients and their family caregivers was developed based on an existing in-person, nurse-delivered intervention. The development process involved: (1) building a multidisciplinary team of content and web design experts, (2) combining key components of the in-person intervention with the unique tailoring and interactive features of a web-based platform, and (3) conducting focus groups and usability testing to obtain feedback from representative program users at multiple time points. Results: Four focus groups with 2-3 patient-caregiver pairs per group (n = 22 total participants) and two iterations of usability testing with four patient-caregiver pairs per session (n = 16 total participants) were conducted. Response to the program's structure, design, and content was favorable, even among users who were older or had limited computer and Internet experience. The program received high ratings for ease of use and overall usability (mean System Usability Score of 89.5 out of 100).Many elements of a nurse-delivered patient-caregiver intervention can be successfully adapted to a web-based format. A multidisciplinary design team and an iterative evaluation process with representative users were instrumental in the development of a usable and well-received web-based program.

    View details for DOI 10.1002/pon.1900

    View details for Web of Science ID 000300987400014

    View details for PubMedID 21830255

  • Trust in the Internet as a Health Resource Among Older Adults: Analysis of Data from a Nationally Representative Survey JOURNAL OF MEDICAL INTERNET RESEARCH Zulman, D. M., Kirch, M., Zheng, K., An, L. C. 2011; 13 (1): 202-211


    Distrust in the Internet as a source of health information remains common among older adults. The influence of this distrust on Internet use for health-related purposes, however, is unclear.The objective of our study was to explore how older adults' trust in the Internet influences their online health-related activities, and to identify potential targets for improving health-related Internet resources for older adults.Data were obtained from a nationally representative, random digit-dial telephone survey of 1450 adults 50 years of age and older in the United States. A model was developed to conceptualize the hypothesized relationships among individual characteristics, distrust, and avoidance of the Internet as a health resource. Multivariate logistic regression analyses were conducted to examine the association between trust in online health information and use of the Internet for health-related purposes. Additional multivariate logistic regression analyses were conducted to identify the key characteristics associated with trust in online health information, adding sequentially the variables hypothesized to account for distrust among older adults: sociodemographic and health characteristics, inexperience and technical difficulties with the Internet, negative feelings toward the Internet, and lack of awareness about the sources providing the health information found online.The mean (SD) age of the study population was 63.7 (10.6) years. Of the 823 (56.8%) Internet users, 628 (76.3%) reported using the Internet as a health resource. Trust in the Internet as a source of health information was associated with using the Internet for a number of health activities, including searching for information about a specific health condition (adjusted OR 4.43, P < .001), purchasing prescription drugs (adjusted OR 2.61, P = .03), and talking with a health care provider about information found online (adjusted OR 2.54, P = .002). Older adults (age ? 65 years) were less likely to trust the Internet as a source of health information (OR 0.63, P = .04), even after adjusting for other sociodemographic characteristics and health and function. This age effect was only slightly attenuated (adjusted OR 0.69, P = .13) after adjusting for inexperience and technical difficulties with the Internet, but it disappeared entirely (adjusted OR 0.96, P = .91) after adjusting for other hypothesized contributors to distrust (including finding the Internet confusing because it provides "too much information," and lacking awareness about the source providing health information found online).Website design features that clearly identify the source and credibility of information and minimize confusion may build trust among older adults and offer an opportunity to increase the utility of the Internet as a health resource for this population.

    View details for DOI 10.2196/jmir.1552

    View details for Web of Science ID 000287447100016

    View details for PubMedID 21324832

  • Patient-Provider Concordance in the Prioritization of Health Conditions Among Hypertensive Diabetes Patients Zulman, D. M., Kerr, E. A., Hofer, T. P., Heisler, M., Zikmund-Fisher, B. J. SPRINGER. 2010: 408-414


    Many patients with diabetes have multiple other chronic conditions, but little is known about whether these patients and their primary care providers agree on the relative importance that they assign these comorbidities.To understand patterns of patient-provider concordance in the prioritization of health conditions in patients with multimorbidity.Prospective cohort study of 92 primary care providers and 1,169 of their diabetic patients with elevated clinic triage blood pressure (> or = 140/90) at nine Midwest VA facilities.We constructed a patient-provider concordance score based on responses to surveys in which patients were asked to rank their most important health concerns and their providers were asked to rank the most important conditions likely to affect that patient's health outcomes. We then calculated the change in predicted probability of concordance when the patient reported having poor health status, pain or depression, or competing demands (issues that were more pressing than his health), controlling for both patient and provider characteristics.For 714 pairs (72%), providers ranked the patient's most important concern in their list of three conditions. Both patients and providers ranked diabetes and hypertension most frequently; however, providers were more likely to rank hypertension as most important (38% vs. 18%). Patients were more likely than providers to prioritize symptomatic conditions such as pain, depression, and breathing problems. The predicted probability of patient-provider concordance decreased when a patient reported having poor health status (55% vs. 64%, p < 0.01) or non-health competing demands (46% vs. 62%, p < 0.01).Patients and their primary care providers often agreed on the most important health conditions affecting patients with multimorbidity, but this concordance was lower for patients with poor health status or non-health competing demands. Interventions that increase provider awareness about symptomatic concerns and competing demands may improve chronic disease management in these vulnerable patients.

    View details for DOI 10.1007/s11606-009-1232-1

    View details for Web of Science ID 000276721900010

    View details for PubMedID 20127197

  • Optimizing Statin Treatment for Primary Prevention of Coronary Artery Disease ANNALS OF INTERNAL MEDICINE Hayward, R. A., Krumholz, H. M., Zulman, D. M., Timbie, J. W., Vijan, S. 2010; 152 (2): 69-?


    Although treating to lipid targets ("treat to target") is widely recommended for coronary artery disease (CAD) prevention, some have advocated administering fixed doses of statins based on a person's estimated net benefit ("tailored treatment").To examine how a tailored treatment approach to statin therapy compares with a treat-to-target approach.Simulated model of population-level effects of treat-to-target and tailored treatment approaches to statin therapy.Statin trials from 1994 to 2009 and nationally representative CAD risk factor data.U.S. persons aged 30 to 75 years with no history of myocardial infarction.Lifetime effects of 5 years of treatment.Societal and patient.Tailored treatment based on a person's 5-year CAD risk (simvastatin, 40 mg, for 5% to 15% CAD risk and atorvastatin, 40 mg, for CAD risk >15%) versus treat-to-target approaches that escalate statin dose per National Cholesterol Education Program [NCEP] III guidelines (including an intensive approach that advances treatment whenever intensification is optional by NCEP III criteria).Quality-adjusted life-years (QALYs).Compared with the standard NCEP III approach, the intensive NCEP III approach treated 15 million more persons and saved 570,000 more QALYs over 5 years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500,000 more QALYs and treated fewer persons with high-dose statins.No circumstances were found in which a treat-to-target approach was preferable to tailored treatment.Model assumptions were based on available clinical data, which included few persons 75 years or older.A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol-based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach.Department of Veteran Affairs Health Services Research & Development Service's Quality Enhancement Research Initiative.

    View details for Web of Science ID 000273953000001

    View details for PubMedID 20083825

  • UCLA mobile clinic project JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Hastings, J., Zulman, D., Wali, S. 2007; 18 (4): 744-748


    We report on a man seeking care at the UCLA mobile clinic, illustrating and then discussing the challenges of caring for people who are homeless (especially mental illness and potential distrust of providers). Student-run free clinics can be beneficial but further research must examine how well such clinics meet homeless patients' needs.

    View details for Web of Science ID 000252211100004

    View details for PubMedID 17982203

  • State Long Term Care Ombudsman Programs: Factors associated with perceived effectiveness GERONTOLOGIST Estes, C. L., Zulman, D. M., Goldberg, S. C., Ogawa, D. D. 2004; 44 (1): 104-115


    This article reports findings from a nationwide study on factors associated with the perceived effectiveness of state Long Term Care Ombudsman Programs (LTCOPs).Researchers conducted telephone interviews with ombudsmen from the 50 state programs as well as from Washington, DC, and Puerto Rico. Data from the National Ombudsman Reporting System were incorporated into the study, and statistical tests analyze associations between self-rated program effectiveness and adequacy of resources, organizational placement-autonomy, interorganizational relationships, and other variables.Several factors limit the perceived effectiveness of state LTCOPs, including insufficient funding and insufficient LTCOP autonomy caused by organizational placement. Despite these problem areas, state ombudsmen report that their programs meet statutorily mandated requirements with varying degrees of effectiveness. Findings show significant positive associations between program funding and paid and volunteer staff levels and between the ratio of long-term care beds per ombudsman and the percentage of nursing facilities visited. Sufficient funding is positively associated with perceived effectiveness of work with nursing facilities.Sufficient resources, sufficient organizational autonomy, and a supportive political and social environment are key elements in achieving varying types of perceived effectiveness in the state LTCOPs. Research is needed to extend this work to local ombudsman programs and to compare self-rated effectiveness with other outcome measures.

    View details for Web of Science ID 000189164000012

    View details for PubMedID 14978326

  • Visual impairment and patterns of winter seasonal depression: Seeing the light? JOURNAL OF VISUAL IMPAIRMENT & BLINDNESS Oren, D. A., Zulman, D. M., Needham, W. E., Berman, R. M., Anand, A., Charney, D. S. 2001; 95 (4): 226-229

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