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Dr. Sarah Chen
Stanford · NLP & interpretability
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Arthur Lee
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University of Pennsylvania · Rehabilitation Medicine
Arthur Lee, MD, is an Assistant Professor of Pediatrics specializing in Nephrology at the Perelman School of Medicine at the University of Pennsylvania. He is an attending physician in the Division of Nephrology at the Children's Hospital of Philadelphia. Dr. Lee's educational background includes a BS in Cellular & Molecular Biology from the University of Michigan (2013), an MD from the University of Virginia School of Medicine (2018), and a Master’s in Translational Research from the University of Pennsylvania School of Medicine (2025). His research focuses on pediatric chronic kidney disease, with particular interest in metabolomic and proteomic profiling, gut microbiome-derived toxins, and neurocognitive outcomes related to kidney function. Dr. Lee has contributed to investigations into biomarkers and disease progression in children with CKD, utilizing advanced analytical techniques such as natural language processing and metabolomics to better understand disease mechanisms and potential therapeutic targets.
INQUIRY The Journal of Health Care Organization Provision and Financing · 2025-08-01 · 1 citations
articleOpen access
Patients with limited English proficiency (LEP) are more likely to experience suboptimal health care outcomes, including avoidable emergency department visits and hospital readmissions. Despite legal requirements in the United States to provide patients with LEP language access services such as certified interpreters during care encounters, gaps in these necessary care processes persist. Nurses provide the majority of direct care to patients with LEP in hospitals and oversee the implementation of necessary language access services. The objective of this qualitative study was to describe nurses' experiences providing care to patients with LEP in hospitals to inform actionable strategies for high-quality patient care for this population. A directed content and thematic analysis of 1295 open text responses from the RN4CAST-NY/IL survey of hospital nurses was conducted, informed by the Social Ecological Model. Four themes were identified: (1) Sufficient and Expert Nurse Staffing ; (2) Community-Integrated Teams and Programs; (3) Variation in Language Access Availability and Modalities; and (4) Tailored Language Access. Nurse-endorsed strategies to improve LEP patient care, informed by the themes, include: improving the adequacy and expertise of nurse staffing to include a multilingual workforce; developing community-integrated teams and programs informed by the lived experiences of LEP patients; developing hospital standards for the type of language access services patients receive in care encounters; and developing protocols to ensure that tailored services are delivered to patients depending on their unique care needs (eg, visual or hearing impairment).
Journal of the American Geriatrics Society · 2025-08-28
articleOpen access
BACKGROUND: Goals of care conversations and documentation of life-sustaining treatment (LST) preferences through durable, portable medical orders are critical for aligning care with patient values. The stability of patient preferences over time remains uncertain, particularly among community-dwelling adults. The Department of Veterans Affairs Life-Sustaining Treatment Decisions Initiative provides a unique opportunity to examine preference trajectories among seriously ill Veterans using longitudinal real-world data. This analysis aimed to: identify cardiopulmonary resuscitation (CPR) preference trajectories, describe Veterans' characteristics by trajectory, and examine associations between trajectories and demographic/clinical factors. METHODS: This longitudinal observational analysis used VA Corporate Data Warehouse data to identify the population of Veterans with completed LST templates as of October 1, 2019 (N = 161,725). CPR preference (full code or do-not-resuscitate [DNR]) over 39 months was analyzed for stability using sequence analysis, and CPR preference trajectories were identified. Veterans' characteristics were compared across trajectories, and multinomial logistic regression was used to assess associations with trajectory membership. RESULTS: Four CPR preference trajectories were identified: (1) persistent preference for DNR (39.8%), (2) code status fluctuation with early mortality (8.7%), (3) code status fluctuation with later mortality (7.3%), and (4) persistent preference for full code (44.3%). Older Veterans were more likely to persist in DNR preferences, while younger Veterans were in full code. Veterans having higher baseline comorbidities, chronic conditions such as heart failure, and higher hospitalization rates were at greater risk of having fluctuating preferences. Those with dementia had a greater likelihood of persistent DNR. CONCLUSIONS: This analysis provides critical insights into the complexity of CPR preference trajectories among Veterans, highlighting the need for nuanced, patient-centered approaches to advance care planning. By addressing dynamic clinical factors, leveraging hospitalizations as strategic opportunities, and incorporating culturally sensitive communication, healthcare providers can improve the alignment of treatment preferences with patients' evolving goals and values.
BACKGROUND: Bereaved family members of racial/ethnic minority Veterans are less likely than families of White Veterans to provide favorable overall ratings of end-of-life (EOL) care quality; however, the underlying mechanisms for these differences have not been explored. The objective of this study was to examine whether a set of EOL care process measures mediated the association between Veteran race/ethnicity and bereaved families' overall rating of the quality of EOL care in VA medical centers (VAMCs). METHODS: A retrospective, cross-sectional analysis of linked Bereaved Family Survey (BFS), administrative and clinical data was conducted. The sample included 17,911 Veterans (mean age: 73.7; SD: 11.6) who died on an acute or intensive care unit across 121 VAMCs between October 2010 and September 2015. Mediation analyses were used to assess whether five care processes (potentially burdensome transitions, high-intensity EOL treatment, and the BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits) significantly affected the association between Veteran race/ethnicity and a poor/fair BFS overall rating. RESULTS: Potentially burdensome transitions, high-intensity EOL treatment, and the three BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits did not substantially mediate the relationship between Veteran race/ethnicity and poor/fair overall ratings of quality of EOL care by bereaved family members. CONCLUSIONS: The reasons underlying poorer ratings of quality of EOL care among bereaved family members of racial/ethnic minority Veterans remain largely unexplained. More research on identifying potential mechanisms, including experiences of racism, and the unique EOL care needs of racial and ethnic minority Veterans and their families is warranted.
BACKGROUND: Few researchers have examined the organizational features of high-performing and low-performing hospitals for COVID-19 mortality during the pandemic, and how differences in hospital performance contributed to mortality disparities among socially vulnerable patients hospitalized with COVID-19. OBJECTIVES: Our objectives were (a) to identify high- and low-performing hospitals on COVID-19 inpatient mortality and describe their distinguishing organizational characteristics, including nursing resources, and (b) to assess whether patients admitted to high-performing hospitals differed by social vulnerability level. METHODS: This analysis used linked nurse survey, hospital, and claims data for 73,792 hospitalized older adults diagnosed with COVID-19 across 96 New York and Illinois hospitals between January 1, 2020, and December 31, 2020. A robust benchmarking approach was used to identify high- and low-performing hospitals on 30-day inpatient mortality. We computed the cumulative proportion of admissions for patients in the highest and lowest social vulnerability index quartiles to the hospitals ranked by performance. RESULTS: The average mortality rate in the high-performing hospitals was 16.2% compared to 31.5% in the low-performing hospitals. Compared to low-performing hospitals, high-performing hospitals had more favorable nurse work environments and lower patient-to-nurse ratios. About half the patients in the lowest social vulnerability quartile (least vulnerable) were admitted to hospitals in the top-performing tertile of hospitals compared to 38% of patients in the highest social vulnerability quartile (most vulnerable). DISCUSSION: Nursing resources were a central feature of a high-performing hospital for COVID-19 mortality during the early stages of the pandemic. Patients diagnosed with COVID-19 who were admitted from the most socially vulnerable communities were less likely to be admitted to high-performing hospitals. Increasing nursing resources-particularly in hospitals that serve socially vulnerable communities-could be a key strategy for preparing for future public health emergencies and addressing health disparities.
Acute kidney injury (AKI) affects approximately 20% of hospitalized patients and is associated with higher mortality, extended hospital stay, and increased costs. While various strategies have been proposed to improve AKI management, the impact of nursing resources on AKI outcomes has not been explored. We sought to examine the association between nursing resources and 30-day mortality among patients hospitalized with AKI. Using a cross-sectional study design, we linked data from the CMS Medicare Provider Analysis and Review file, American Hospital Association Annual Survey, and RN4CAST-NY/IL survey of registered nurses. We identified 24,368 Medicare beneficiaries aged 18-99 years with a primary diagnosis of AKI hospitalized in 155 hospitals in New York and Illinois in 2021. The primary outcome was 30-day mortality. Key independent variables included nurse staffing (patient-to-nurse ratio) and nurse education (proportion of nurses holding a bachelor's degree or higher). Covariates were patient demographics, comorbidities, and hospital characteristics. The 30-day mortality rate was 10.5%. In adjusted logistic regression models, each additional patient per RN increased the odds of 30-day mortality by 7% (OR = 1.07, 95% CI [1.01-1.13], p < 0.05). For each 10-point increase in the proportion of nurses with a bachelor's degree or higher, the odds of 30-day mortality decreased by 9% (OR = 0.91, 95% CI [0.88-0.95], p < 0.001). Better nurse staffing and higher proportions of nurses with a bachelor's degree or higher are associated with lower 30-day mortality among patients hospitalized with AKI. These findings underscore the significance of nursing in AKI outcomes and suggest that hospitals should prioritize investing in nursing resources to enhance AKI outcomes.
The Veterans Health Administration (VHA), the largest employer of nurses in the United States, has more than 120,000 nursing personnel providing care to over 9 million Veterans across diverse settings. Despite nursing's central role in delivering and sustaining care, research on strengthening the nursing workforce and optimizing nursing practice has remained underdeveloped in VHA. To address this gap, VHA's Office of Research and Development, in partnership with the Office of Nursing Services, convened a State of the Art (SOTA) conference in November 2023 focused on nursing. The Nursing SOTA brought together nurses, researchers, operational leaders, and other stakeholders to review current evidence, identify research gaps, and develop recommendations. Five priority areas were identified: pressure injury prevention and treatment, care coordination models, social drivers of health, nurse staffing and care models, and the nursing work environment. Cross-cutting themes included the need for stronger data infrastructure and expanded support for the VHA nursing science workforce. Conference recommendations were incorporated into VHA's 2024 Health Systems Research Priorities and are expected to inform future research, policy, and practice aimed at advancing nursing science and improving care for Veterans.
Importance: Patients from socially disadvantaged backgrounds experience disproportionately worse health care outcomes. Nurses provide most care to patients in hospitals and are informants of health care quality and equity. Objective: To understand what hospital nurses say helps or hinders their ability to provide quality care to socially disadvantaged populations. Design, Setting, and Participants: This qualitative study involved a directed content analysis of open-text responses from the RN4CAST-NY/IL survey, which was conducted between April and June 2021. Participants were registered nurses licensed to work in 58 New York and Illinois hospitals identified as high-performing (25 hospitals) and low-performing (33 hospitals) for COVID-19 mortality outcomes in 2021 from a larger quantitative study. The Social Ecological Model informed the study codebook; inductive and deductive coding of the data and content analysis were conducted from March to October 2024. Exposure: Direct care hospital nurses who participated in the RN4CAST-NY/IL survey. Main Outcomes and Measures: Open-text responses were from nurses who answered the survey question, "What helps (or hinders) your ability to provide quality care to vulnerable populations? (e.g. low SES, housing insecurity/homeless, racial/ethnic minorities, immigrant, limited English proficiency)?" Results: A total of 1084 nurses (mean [SD] age, 47.1 [18.2] years) responded to the survey. Most respondents identified as female (986 respondents [91.0%]) and were staff or direct care nurses (765 respondents [70.6%]) with at least a bachelor's degree (968 respondents [89.6%]). With regard to race and ethnicity, 127 respondents (11.8%) were Asian, 156 (14.5%) were Black or African American, 89 (8.3%) were Hispanic, 693 (64.2%) were White, and 97 (8.9%) were other races. They had a mean (SD) of 18.9 (14.0) years of experience. Six themes described what helped or hindered quality care: (1) profits over patients, (2) care continuity and hospital-community partnerships, (3) insufficient staffing and time constraints, (4) technology to address language barriers, (5) patients' determinants of health, and (6) individual nurses' beliefs and backgrounds. Nurses proposed improving health care workforce diversity, strengthening community resources for patients, and advancing tailored cultural competency education as solutions to improve care for socially disadvantaged patients. Conclusions and Relevance: In this qualitative study and directed content analysis of 1084 open-text responses, nurses identified systemic, institutional, community, and individual clinician-level approaches to improve care for socially disadvantaged populations for equitable care delivery. Nurses' direct care experiences can inform hospital strategies to improve care for this population.
Abstract We designed Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED), a five-year VA-funded quality improvement program, to support VA clinicians with data and tools to ensure consistent documentation of life sustaining treatment (LST) preferences for Veterans who receive care in community nursing homes (CNHs). Guided by the VA Quality Enhancement Research Initiative (QUERI) Roadmap for Implementation and Quality Improvement, we designed the pre-implementation phase. Over 5 months, we conducted virtual meetings with partners at six VA CNH programs to: 1) engage site leadership and recruit champions; 2) assess barriers and facilitators to documenting LST preferences; 3) develop process maps of existing workflows; and 4) evaluate baseline knowledge, skills and resources related to these clinical practices. Through individual interviews (n=41) and 14 meetings with clinical and administrative partners, we recruited 19 champions. Common barriers included lack of knowledge/training and confusion about roles/responsibilities among VA CNH program clinicians. Facilitators included access to VA and CNH electronic medical records and positive relationships among VA and CNH staff. Across the programs in this sample, process maps revealed variability in formal systems for ensuring LST documentation in CNHs and VA. Using these findings, we tailored educational resources, developed site-specific audit tools for tracking VA and CNH LST documentation, and created processes that integrated LST documentation into existing VA CNH program workflows. Pre-implementation proved to be a critical step to ensure success and guided us in developing individualized implementation plans and addressing potential challenges to evidence-based practice adoption.
