Theodore J Iwashyna

Summary

Affiliation: University of Michigan
Country: USA

Publications

  1. pmc Becoming a high reliability organization
    Marlys K Christianson
    Rotman School of Management, University of Toronto, Toronto, ON, Canada
    Crit Care 15:314. 2011
  2. ncbi request reprint Instrumental variable analyses. Exploiting natural randomness to understand causal mechanisms
    Theodore J Iwashyna
    Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
    Ann Am Thorac Soc 10:255-60. 2013
  3. doi request reprint Guided transfer of critically ill patients: where patients are transferred can be an informed choice
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor VA HSR and D Center of Excellence, Ann Arbor, Michigan, USA
    Curr Opin Crit Care 17:641-7. 2011
  4. doi request reprint The burdens of survivorship: an approach to thinking about long-term outcomes after critical illness
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
    Semin Respir Crit Care Med 33:327-38. 2012
  5. doi request reprint The incomplete infrastructure for interhospital patient transfer
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Center for Clinical Management Research, Ann Arbor VA HSR and D Center of Excellence, Ann Arbor, MI, USA
    Crit Care Med 40:2470-8. 2012
  6. pmc Population burden of long-term survivorship after severe sepsis in older Americans
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
    J Am Geriatr Soc 60:1070-7. 2012
  7. pmc Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor, USA
    Am J Respir Crit Care Med 185:835-41. 2012
  8. pmc Accuracy of the discharge destination field in administrative data for identifying transfer to a long-term acute care hospital
    Jeremy M Kahn
    Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Blockley Hall 723, 423 Guardian Drive, Philadelphia, PA 19104
    BMC Res Notes 3:205. 2010
  9. pmc Perceived barriers to the regionalization of adult critical care in the United States: a qualitative preliminary study
    Jeremy M Kahn
    Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
    BMC Health Serv Res 8:239. 2008
  10. pmc Interhospital transfers among Medicare beneficiaries admitted for acute myocardial infarction at nonrevascularization hospitals
    Theodore J Iwashyna
    Department of Internal Medicine, University of Michigan Medical School, 300 North Ingalls, Ann Arbor, MI 48109 5419, USA
    Circ Cardiovasc Qual Outcomes 3:468-75. 2010

Collaborators

Detail Information

Publications53

  1. pmc Becoming a high reliability organization
    Marlys K Christianson
    Rotman School of Management, University of Toronto, Toronto, ON, Canada
    Crit Care 15:314. 2011
    ..Given the complexity of patient care in the ICU, the potential for medical error, and the particular sensitivity of critically ill patients to harm, high reliability organizing principles hold promise for improving ICU patient care...
  2. ncbi request reprint Instrumental variable analyses. Exploiting natural randomness to understand causal mechanisms
    Theodore J Iwashyna
    Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
    Ann Am Thorac Soc 10:255-60. 2013
    ..2) Other than through the specific treatment being tested, is there any other way the instrumental variable could influence the outcome? (3) Does anything cause patients to both receive the instrumental variable and receive the outcome?..
  3. doi request reprint Guided transfer of critically ill patients: where patients are transferred can be an informed choice
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor VA HSR and D Center of Excellence, Ann Arbor, Michigan, USA
    Curr Opin Crit Care 17:641-7. 2011
    ....
  4. doi request reprint The burdens of survivorship: an approach to thinking about long-term outcomes after critical illness
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
    Semin Respir Crit Care Med 33:327-38. 2012
    ..This article provides a discussion of the ICF specific to the intensive care unit and the disablement process, with particular attention to new opportunities for intervention and their implications for cost and quality of life...
  5. doi request reprint The incomplete infrastructure for interhospital patient transfer
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Center for Clinical Management Research, Ann Arbor VA HSR and D Center of Excellence, Ann Arbor, MI, USA
    Crit Care Med 40:2470-8. 2012
    ..This article sought to review the data on the current patterns of use of interhospital transfer and identify systematic barriers to optimal integration of transfer as a mechanism for improving patient outcomes and value of care...
  6. pmc Population burden of long-term survivorship after severe sepsis in older Americans
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
    J Am Geriatr Soc 60:1070-7. 2012
    ..To ascertain the absolute number of Medicare beneficiaries surviving at least 3 years after severe sepsis and to estimate their burden of cognitive dysfunction and disability...
  7. pmc Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions
    Theodore J Iwashyna
    Department of Medicine, University of Michigan, Ann Arbor, USA
    Am J Respir Crit Care Med 185:835-41. 2012
    ..Survivors of critical illness suffer significant limitations and disabilities...
  8. pmc Accuracy of the discharge destination field in administrative data for identifying transfer to a long-term acute care hospital
    Jeremy M Kahn
    Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Blockley Hall 723, 423 Guardian Drive, Philadelphia, PA 19104
    BMC Res Notes 3:205. 2010
    ....
  9. pmc Perceived barriers to the regionalization of adult critical care in the United States: a qualitative preliminary study
    Jeremy M Kahn
    Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
    BMC Health Serv Res 8:239. 2008
    ..We sought to develop a framework for understanding clinician attitudes toward regionalization and potential barriers to developing a tiered, regionalized system of care in the United States...
  10. pmc Interhospital transfers among Medicare beneficiaries admitted for acute myocardial infarction at nonrevascularization hospitals
    Theodore J Iwashyna
    Department of Internal Medicine, University of Michigan Medical School, 300 North Ingalls, Ann Arbor, MI 48109 5419, USA
    Circ Cardiovasc Qual Outcomes 3:468-75. 2010
    ....
  11. pmc The structure of critical care transfer networks
    Theodore J Iwashyna
    Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
    Med Care 47:787-93. 2009
    ..These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival...
  12. pmc Long-term cognitive impairment and functional disability among survivors of severe sepsis
    Theodore J Iwashyna
    Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
    JAMA 304:1787-94. 2010
    ..Although the incidence of severe sepsis is high and increasing, the magnitude of patients' long-term cognitive and functional limitations after sepsis is unknown...
  13. pmc Uncharted paths: hospital networks in critical care
    Theodore J Iwashyna
    Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
    Chest 135:827-33. 2009
    ....
  14. ncbi request reprint Despite variation in volume, Veterans Affairs hospitals show consistent outcomes among patients with non-postoperative mechanical ventilation
    Colin R Cooke
    From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
    Crit Care Med 40:2569-75. 2012
    ..To assess the relationship between volume of nonoperative mechanically ventilated patients receiving care in a specific Veterans Health Administration hospital and their mortality...
  15. ncbi request reprint Critical care use during the course of serious illness
    Theodore J Iwashyna
    Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia 19103, USA
    Am J Respir Crit Care Med 170:981-6. 2004
    ..Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs...
  16. pmc Acute care and long-term mortality among elderly patients with intracerebral hemorrhage who undergo chronic life-sustaining procedures
    Lesli E Skolarus
    Stroke Program, University of Michigan Medical School, Ann Arbor, MI, USA
    J Stroke Cerebrovasc Dis 22:15-21. 2013
    ..Medicare payments for patients who undergo tracheostomy are substantial. More information about functional outcomes is needed...
  17. pmc Intensive care unit occupancy and patient outcomes
    Theodore J Iwashyna
    Department of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
    Crit Care Med 37:1545-57. 2009
    ..Although intensive care units (ICUs) with higher overall patient volume may achieve better outcomes than lower volume ICUs, there are few data on the effects of increasing patient loads on patients within the ICU...
  18. ncbi request reprint Hospital factors associated with discharge bias in ICU performance measurement
    Lora A Reineck
    1Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 2CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 3Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA 4Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI 5Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI
    Crit Care Med 42:1055-64. 2014
    ..The aim of this study was to quantify variation in discharge bias across hospitals and determine the hospital characteristics associated with greater discharge bias...
  19. ncbi request reprint Organisational characteristics associated with the use of daily interruption of sedation in US hospitals: a national study
    Melissa A Miller
    Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
    BMJ Qual Saf 21:145-51. 2012
    ..The authors test the hypothesis that specific hospital organisational characteristics are associated with routine use of DIS...
  20. ncbi request reprint Identifying patients with severe sepsis using administrative claims: patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis
    Theodore J Iwashyna
    Department of Medicine, University of Michigan VA Center for Clinical Management Research VA Geriatrics Research, Education and Clinical Center, Ann Arbor, MI
    Med Care 52:e39-43. 2014
    ..We conducted a single center, patient-level validation of 1 common implementation of the severe sepsis definition, the so-called "Angus" implementation...
  21. pmc Diverse attitudes to and understandings of spontaneous awakening trials: results from a statewide quality improvement collaborative*
    Melissa A Miller
    Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
    Crit Care Med 41:1976-82. 2013
    ....
  22. pmc Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study
    Mina O Rakoski
    Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109 5362, USA
    Hepatology 55:184-91. 2012
    ..Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person...
  23. pmc Implementation challenges in the intensive care unit: the why, who, and how of daily interruption of sedation
    Melissa A Miller
    Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI 48109 5360, USA
    J Crit Care 27:218.e1-7. 2012
    ..We sought to identify new barriers to daily interruption of sedation...
  24. doi request reprint Functional outcomes of general medical patients with severe sepsis
    Andrew J Odden
    Department of Medicine, University of Michigan Medical School, 1500 E, Medical Center Drive, Ann Arbor, MI 48109, USA
    BMC Infect Dis 13:588. 2013
    ....
  25. pmc Revenue, relationships and routines: the social organization of acute myocardial infarction patient transfers in the United States
    Tiffany C Veinot
    School of Information and School of Public Health, University of Michigan, Ann Arbor, MI 48109 1285, USA
    Soc Sci Med 75:1800-10. 2012
    ..We consider the implications of routinization and institutional imperatives for health policy, quality improvement and health informatics interventions...
  26. doi request reprint Race and timeliness of transfer for revascularization in patients with acute myocardial infarction
    Colin R Cooke
    Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, USA
    Med Care 49:662-7. 2011
    ..We sought to determine whether the timeliness of hospital transfer and quality of destination hospitals differed between black and white patients...
  27. pmc Regional variation in the association between advance directives and end-of-life Medicare expenditures
    Lauren Hersch Nicholas
    Institute for Social Research, University of Michigan, Ann Arbor, MI 48104, USA
    JAMA 306:1447-53. 2011
    ..It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments...
  28. ncbi request reprint Marriage, widowhood, and health-care use
    Theodore J Iwashyna
    Department of Medicine, Hospital of the University of Pennsylvania, Pennsylvania, PA, USA
    Soc Sci Med 57:2137-47. 2003
    ..We suggest that these patterns are most consistent with spouses exerting their benefits by functioning as higher-order decision-makers than as home health assistants...
  29. ncbi request reprint Quality of care and interhospital collaboration: a study of patient transfers in Italy
    Alessandro Lomi
    Faculty of Economics, University of Italian Switzerland, Lugano, Switzerland Department of Management, Catholic University of the Sacred Heart, Rome, Italy Department of Mathematics and Statistics, University of Melbourne, Vic, Australia Department of International Business and Economics, Centre for Business Network Analysis, University of Greenwich, Old Royal Naval College, London, UK Department of Internal Medicine, University of Michigan, Ann Arbor, MI
    Med Care 52:407-14. 2014
    ..We test whether interorganizational relations provide individual patients access to higher quality providers of care...
  30. pmc Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals
    Meeta Prasad
    Division of Pulmonary, Allergy, and Critical Care Medicine MP, JDC, JMK, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
    Crit Care Med 37:2564-9. 2009
    ..The United States instituted restrictions on resident work-hours in July 2003. The clinical impact of this reform on critically ill patients is unknown...
  31. pmc The epidemiology of acute organ system dysfunction from severe sepsis outside of the intensive care unit
    Jeffrey M Rohde
    Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA
    J Hosp Med 8:243-7. 2013
    ..Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (ICU). However, nearly half of all patients with severe sepsis are cared for outside the ICU...
  32. pmc Do hospitals alter patient care effort allocations under pay-for-performance?
    Lauren Hersch Nicholas
    Institute for Social Research and Center for Healthcare Outcomes and Policy, University of Michigan, 426 Thompson St, Ann Arbor, MI 48104, USA
    Health Serv Res 46:61-81. 2011
    ..To determine whether hospitals increase efforts on easy tasks relative to difficult tasks to improve scores under pay-for-performance (P4P) incentives...
  33. pmc The lack of effect of market structure on hospice use
    Theodore J Iwashyna
    Department of Medicine, Hospital of the University of Pennsylvania, USA
    Health Serv Res 37:1531-51. 2002
    ..To describe the relative importance of health care market structure and county-level demographics in determining rates of hospice use...
  34. ncbi request reprint Low use of durable medical equipment by chronically disabled elderly
    Theodore J Iwashyna
    Department of Medicine, Leonard Davis Institute, and Center for Clinical Epidemiology and Biostatistics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19130, USA
    J Pain Symptom Manage 33:324-30. 2007
    ..Fewer than half the chronically disabled, and less than one-quarter of the newly disabled, received any DME from Medicare. These data suggest underuse of the benefit by the disabled elderly...
  35. pmc Longitudinal influences of friends and parents upon unprotected vaginal intercourse in adolescents
    Catherine Kim
    Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
    Contraception 83:138-44. 2011
    ..Both friends and parents may influence occurrence of adolescent sexual intercourse, but these influences have not been studied together and prospectively...
  36. ncbi request reprint Issues of survivorship are rarely addressed during intensive care unit stays. Baseline results from a statewide quality improvement collaborative
    Sushant Govindan
    1 Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
    Ann Am Thorac Soc 11:587-91. 2014
    ....
  37. doi request reprint Adoption of ICU telemedicine in the United States
    Jeremy M Kahn
    1Clinical Research, Investigation and Systems Modeling of Acute Illness CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 2Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 3Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 4Division of Pulmonary and Critical Care Medicine, University of Michigan School of Medicine, Ann Arbor, MI 5Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
    Crit Care Med 42:362-8. 2014
    ..ICU telemedicine is a novel approach for providing critical care services from a distance. We sought to study the extent of use and patterns of adoption of this technology in U.S. ICUs...
  38. pmc Using existing data to address important clinical questions in critical care
    Colin R Cooke
    Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
    Crit Care Med 41:886-96. 2013
    ....
  39. pmc Limiting the spread of highly resistant hospital-acquired microorganisms via critical care transfers: a simulation study
    Umanka H Karkada
    School of Information, University of Michigan, Ann Arbor, MI, USA
    Intensive Care Med 37:1633-40. 2011
    ..We examine the extent to which transfers of critically ill patients could be a vector for the wide spread of highly resistant organisms, and compare the efficiency of different approaches to targeting infection control resources...
  40. pmc Which patients and where: a qualitative study of patient transfers from community hospitals
    Emily A Bosk
    Department of Sociology and School of Social Work, University of Michigan, Ann Arbor, MI 48109 5419, USA
    Med Care 49:592-8. 2011
    ..A microlevel analysis of the processes of patient transfer has not earlier been carried out...
  41. ncbi request reprint Death certificates underestimate infections as proximal causes of death in the U.S
    Sushant Govindan
    Department of Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
    PLoS ONE 9:e97714. 2014
    ..We analyzed the rate and patterns of disagreement between death certificate data and hospital claims for patients who died during an inpatient hospitalization...
  42. doi request reprint Expansion of invasive cardiac services in the United States
    Jill R Horwitz
    School of Law, University of California Los Angeles, Los Angeles, CA 90095, USA
    Circulation 128:803-10. 2013
    ....
  43. pmc Small area variations in out-of-hospital cardiac arrest: does the neighborhood matter?
    Comilla Sasson
    University of Michigan, Ann Arbor, Michigan, USA
    Ann Intern Med 153:19-22. 2010
    ..The incidence and outcomes of out-of-hospital cardiac arrest vary widely across cities. It is unknown whether similar differences exist at the neighborhood level...
  44. ncbi request reprint Disease-specific patterns of hospice and related healthcare use in an incidence cohort of seriously ill elderly patients
    Theodore J Iwashyna
    Department of Medicine, Hospital of the University at Pennsylvania, Philadelphia, Pennsylvania, USA
    J Palliat Med 5:531-8. 2002
    ..7%. Among decedents with cancer diagnoses, rates vary from 15.2% to 35.2%. For the cohort overall, 14.2% of male decedents and 12.4% of female decedents used hospice. Patterns of end-of-life care vary substantially according to diagnosis...
  45. doi request reprint The impact of residents, interns, and attendings on inpatient laboratory ordering patterns: a report from one university's hospitalist service
    Theodore J Iwashyna
    Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
    Acad Med 86:139-45. 2011
    ..To examine the laboratory test ordering patterns of interns to determine the effects of more senior residents' and attendings' supervision on trainees' patterns and residents' perceptions of control in test ordering...
  46. ncbi request reprint Increased 1-year healthcare use in survivors of severe sepsis
    Hallie C Prescott
    1 Department of Medicine, University of Michigan, Ann Arbor, Michigan
    Am J Respir Crit Care Med 190:62-9. 2014
    ..4% [95% confidence interval, 2.8-8.1%]; P < 0.001). Conclusions: Healthcare use is markedly elevated after severe sepsis, and post-discharge management may be an opportunity to reduce resource use. ..
  47. ncbi request reprint Prolonged duration ECMO for ARDS: futility, native lung recovery, or transplantation?
    Andrew A Rosenberg
    From the Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan University of Michigan Health Systems, Ann Arbor, Michigan Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan Division of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan and Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
    ASAIO J 59:642-50. 2013
    ..We recommend redefining irreversible lung injury and futility in ECMO. ..
  48. pmc Chemotherapy was not associated with cognitive decline in older adults with breast and colorectal cancer: findings from a prospective cohort study
    Victoria A Shaffer
    Department of Health Sciences, School of Health Professions, University of Missouri, Columbia, MO 65221 4290, USA
    Med Care 50:849-55. 2012
    ....
  49. pmc Depressive symptoms in spouses of older patients with severe sepsis
    Dimitry S Davydow
    Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
    Crit Care Med 40:2335-41. 2012
    ....
  50. pmc Wide variation and rising utilization of stroke magnetic resonance imaging: data from 11 states
    James F Burke
    Department of Veterans Affairs, VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, MI, USA
    Ann Neurol 71:179-85. 2012
    ..Magnetic resonance imaging (MRI) is more accurate than computed tomography (CT) for the diagnosis of stroke, but is more costly and time-consuming. We sought to describe changes in MRI utilization from 1999 to 2008...
  51. ncbi request reprint A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-associated pneumonia
    Melissa A Miller
    Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
    J Crit Care 26:280-6. 2011
    ..The aim of this study was to determine whether the use of a polyurethane-cuffed endotracheal tube would result in a decrease in ventilator-associated pneumonia rate...
  52. ncbi request reprint Effectiveness of adjuvant fluorouracil in clinical practice: a population-based cohort study of elderly patients with stage III colon cancer
    Theodore J Iwashyna
    Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
    J Clin Oncol 20:3992-8. 2002
    ..In this study, we ask the following: (1) What is the hazard of death associated with adjuvant 5-FU in the general population of elderly stage III colon cancer patients? (2) Does the hazard vary with patient age?..
  53. pmc Racial, ethnic, and affluence differences in elderly patients' use of teaching hospitals
    Theodore J Iwashyna
    Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, USA
    J Gen Intern Med 17:696-703. 2002
    ..To understand the role of race, ethnicity, and affluence in elderly patients' use of teaching hospitals when they have that option...