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Most residency programs do not provide trainees with health equity data for their clinic patients.Equity report cards were developed for internal and family medicine residents in a large health system. After considering which equity indictors were available, how to attribute patients to residents, and what level of granularity was feasible, equity reports were created for five ambulatory quality measures. Chi-square tests were used to test the significance of differences in quality measure satisfaction between groups.Attributing patients to the physician who had seen them for the greatest proportion of encounters performed best. Creating equity reports for individual resident panels was not possible due to insufficient numbers. Most measures had sufficient patients when combining all residents' patients. Inequities were identified for four of five examined measures.Creating aggregate equity reports for all primary care residents across multiple equity indicators was feasible, documenting disparities in health care quality.

Background Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents’ competence at identifying and addressing SDOH. Methods Residents’ perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients’ challenges related to SDOH through referrals. Results The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients’ challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. Conclusions Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.

In a survey of older adults at higher risk for COVID-19 complications, we sought to describe expectations of trust in the safety and efficacy of a future COVID-19 vaccine, and level of hesitancy about receiving it. We also assessed whether these expectations were associated with known or suspected contributors to vaccine hesitancy, disparities in vaccine receipt, and potential targets for public health outreach. From May 1-22, 2020, we performed telephone surveys of 601 older adults with chronic conditions in metro Chicago about their COVID-19 experiences and levels of vaccine trust and hesitancy. All participants previously completed assessments of demographics, health status, health literacy and activation. Bivariate associations were performed using t-tests or one-way ANOVA, and multivariate analyses using least square means. Younger age (

Purpose Medical training has traditionally focused on the proximate determinants of disease, with little focus on how social conditions influence health. The authors conducted a scoping review of existing curricula to understand the current programs designed to teach primary care residents about the social determinants of health (SDH). Method In January and March 2017, the authors searched seven databases. Eligible articles focused on primary care residents, described a curriculum related to SDH, were published between January 2007 and January 2017, and were based in the United States. Results Of the initial 5,523 articles identified, 43 met study eligibility criteria. Most programs (29; 67%) were in internal medicine. Sixteen studies (37%) described the curriculum development process. Overall, 20 programs (47%) were short or one-time sessions, and 15 (35%) were longitudinal programs lasting at least 6 months. Thirty-two programs (74%) reported teaching SDH content using didactics, 22 (51%) incorporated experiential learning, and many programs (n = 38; 88%) employed both. Most studies reported satisfaction and/or self-perceived changes in knowledge or attitudes. Conclusions The authors identified wide variation in curriculum development, implementation, and evaluation. They highlight curricula that considered community and resident needs, used conceptual frameworks or engaged multiple stakeholders to select content, used multiple delivery methods, and focused evaluation on changes in skills or behaviors. This review highlights the need not only for systematic, standardized approaches to developing and delivering SDH curricula but also for developing rigorous evaluation of the curricula, particularly effects on resident behavior.

The Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) program aimed to improve health care quality and reduce racial and ethnic disparities in 16 diverse communities in the United States from 2006 to 2015; yet most communities failed to make substantive progress toward advancing health care equity by the program’s end. This qualitative analysis of key stakeholder interviews aims to identify the major contributors to success versus failure in addressing local health disparities during AF4Q and identified five major themes. Three themes highlight challenges related to collecting local data on racial and ethnic health disparities and transitioning from data collection to action. Two themes capture the critical contribution of stakeholder engagement and access to technical expertise to successful efforts. The challenges and facilitators experienced by these 16 AF4Q communities may help inform the disparities reduction efforts of other communities and guide state or federal policies to reduce health disparities.

Despite well-established programs, influenza vaccination rates in US adults are well below federal benchmarks and exhibit well-documented, persistent racial and ethnic disparities. The causes of these disparities are multifactorial and complex, though perceived racial/ethnic discrimination in health care is 1 hypothesized mechanism.To assess the role of perceived discrimination in health care in mediating influenza vaccination RACIAL/ETHNIC disparities in chronically ill US adults (at high risk for influenza-related complications).We utilized 2011-2012 data from the Aligning Forces for Quality Consumer Survey on health and health care (n=8127), nationally representative of chronically ill US adults. Logistic regression marginal effects examined the relationship between race/ethnicity and influenza vaccination, both unadjusted and in multivariate models adjusted for determinants of health service use. We then used binary mediation analysis to calculate and test the significance of the percentage of this relationship mediated by perceived discrimination in health care.Respondents reporting perceived discrimination in health care had half the uptake as those without discrimination (32% vs. 60%, P=0.009). The change in predicted probability of vaccination given perceived discrimination experiences (vs. none) was large but not significant in the fully adjusted model (-0.185; 95% CI, -0.385, 0.014). Perceived discrimination significantly mediated 16% of the unadjusted association between race/ethnicity and influenza vaccination, though this dropped to 6% and lost statistical significance in multivariate models.The causes of persistent racial/ethnic disparities are complex and a single explanation is unlikely to be sufficient. We suggest reevaluation in a larger cohort as well as potential directions for future research.

Care delivery concepts such as healthcare quality, safety, equity, and teamwork are crucial in the care of patients. While the importance of these concepts becomes self-evident to many clerkship students, engaging pre-clerkship students has proven challenging. We created a three-session, case-based learning (CBL) curriculum that deliberately integrated care delivery concepts and basic science content. In this format, students demonstrated increased understanding of concept relevance and faculty assessments showed improved knowledge acquisition. CBL is both feasible and acceptable to pre-clerkship students as a method to teach care delivery topics.

Objective To determine whether racial and ethnic disparities in cholesterol screening persist after controlling for socioeconomic status, access to care and language. Methods Data were obtained from the 2011 Behavioral Risk Factor Surveillance System for men aged 35 and older and women aged 45 and older in accordance with the United States Preventive Services Task Force guidelines. Self-reported cholesterol screening data are presented for 389,039 respondents reflecting over 141 million people. Sequential logistic regression models of the likelihood of never having been screened are presented adjusted for demographic characteristics, health status, behavioral risk factors, socioeconomic status, health care access, and questionnaire language. Results A total of 9.1% of respondents, reflecting almost 13 million individuals, reported never having been screened. After adjustment for socioeconomic status, health care access and Spanish language, disparities between whites and Blacks and Hispanics, but not Asians and Pacific Islanders, were eliminated. Conclusions Lower socioeconomic status, lack of healthcare access and language barriers explained most of the racial and ethnic disparities in cholesterol screening. Expanding insurance coverage, simplifying cardiac risk assessment and improving access to culturally and linguistically appropriate care hold the greatest promise for improving cardiovascular disease screening and treatment for vulnerable populations.

After implementing a multifaceted physician-directed quality improvement (QI) initiative, an increased disparity in low-density lipoprotein (LDL) cholesterol control between white and black diabetes patients was observed. To examine possible causes, a retrospective analysis of 962 black and white patients treated continuously between 2008 and 2010 was performed. At baseline, 55.0% of whites and 49.8% of blacks were controlled (5.2% disparity). The disparity increased, with 61.8% of whites and 44.6% of blacks having control in 2010 (17.2% disparity). Among patients uncontrolled at baseline, blacks were less likely to become controlled. Among patients controlled at baseline, blacks were less likely to remain controlled; accounting for patient characteristics and changes in lipid-lowering drug prescription regimens did not attenuate these relationships. Physician-facing, general QI interventions may be insufficient to produce equity in LDL cholesterol control. Helping patients maintain prior success controlling cholesterol appears as important in addressing this disparity as is helping uncontrolled patients achieve control.

The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed.A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided.The summative research design employed by the evaluation team is discussed.The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program.The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015.This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities.Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) initiative aimed to advance healthcare quality and equity in 16 communities across the United States through multi-stakeholder alliances of healthcare payers, providers, and consumers. Our objectives are (1) to summarize the major approaches and activities undertaken by the AF4Q alliances that were most successful in tracking and implementing programs that aimed to reduce local healthcare disparities by race, ethnicity, and primary language spoken (REL), and socioeconomic status (SES); and (2) to identify the major lessons learned from the successes and failures of the AF4Q alliances to inform other equity-focused initiatives.We analyzed data from 6 rounds of key informant interviews conducted between 2010 and 2015, and triannual progress reports submitted by the alliances to RWJF between 2008 and 2015.Of the 16 AF4Q alliances, 2 succeeded in developing community wide systems to track local healthcare disparities, 5 alliances implemented substantive programs that aimed to reduce local disparities, and 3 alliances were successful in disparity measurement and program implementation. The alliances that were most active in addressing disparities tended to have long-established relationships with relevant community organizations, focused on improving the quality of care provided by safety-net providers, and shifted quickly toward working to address disparities even if their initial efforts to stratify performance measures by REL failed.Few alliances were able to develop community wide systems to track local healthcare disparities or implement large-scale initiatives to reduce disparities during the 7 years that these objectives were advanced by the AF4Q initiative. Establishing robust local disparity-tracking systems and establishing productive relationships with key community stakeholders took substantial time. The AF4Q experience suggests that efforts to reduce disparities should not be held up by disparity measurement challenges.

The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances.Descriptive overview of a multi-site, community-based quality improvement initiative.We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders.The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives.The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative.Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care.Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.

Re-engaging patients who have fallen out of regular care is a challenge for all primary care practices, but especially for federally qualified health centers (FQHCs). We implemented and evaluated a system of proactive telephone and mail outreach within an FQHC serving a predominantly Latino and Spanish-speaking population for patients with diabetes who had not had a visit to the health center for at least six months. The primary study outcome was the proportion of patients who completed a follow-up visit within three months of the outreach. We also examined patient characteristics associated with completing a follow-up visit. Of 208 patients eligible for outreach, 24% (n = 49) completed a follow-up visit. Thirty-six percent (n = 74) had a disconnected or incorrect phone number, 16% (n = 34) were not reached within three phone call attempts, and 20% (n = 22) of letters mailed were returned to sender. Future efforts to re-engage patients in diabetes care should examine shorter intervals before outreach and other outreach strategies.

In recent debates on resident duty hour regulations, attention has been focused primarily on determining the total amount of time residents should spend on patient care and educational activities. But leaders in graduate medical education have long noted the need to fundamentally restructure the content, not just the quantity, of residents’ work days.1–3In particular, major proposals for graduate medical education redesign have sought to ensure that residents’ workloads and tasks are better aligned with the aim of developing highly skilled, capable, and compassionate physicians. On the ground, however, most changes to residents’ workloads—even those changes that might free up time for focused educational activities, such as the redistribution of various administrative and clinical activities from residents to mid-level practitioners, care managers, and other care team members—have been driven by the need to maintain high volume patient throughput in the face of work hour reforms, rather than reflecting a critical reassessment of what residents should be doing throughout the day to optimize their professional development.

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English profi ciency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODS All adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual cli- nician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the out- reach protocol. Outcome measures were compared using the Fisher exact test. RESULTS Analyses were based on 104 patients assigned to the outreach inter- vention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P

Reducing disparities in care requires that health care providers identify populations at risk for suboptimal quality of care. Stratified analyses are often used to examine disparities (eg, by race or sex). However, stratified analyses can be misleading if the variables are confounded. The authors examined disparities in quality within a large ambulatory care practice using both unadjusted and adjusted methods for 18 measures. In unadjusted analyses, differences in quality were identified for 9 measures by race. However, in analyses adjusted simultaneously for race, sex, age, socioeconomic status, and chronic medical conditions, racial differences were apparent for only 4 measures. Women received lower quality care for 4 measures in both unadjusted and adjusted analyses. The pattern of observed disparities can differ significantly based on whether unadjusted or adjusted methods are applied. Health care organizations should consider the routine use of adjusted methods to measure disparities in order to better inform disparity reduction initiatives.

Restructuring payment policies through performance incentive programs to explicitly promote improvements in the quality and value of health care has become a popular strategy for public and private health care payers. But our measures of quality are less than comprehensive, and current performance incentive strategies to improve quality may exacerbate disparities in health care. Despite the proliferation of pay-for-performance (P4P) and other performance incentive programs, data on whether they work to improve quality are scant and, where data exist, the results have been mixed. Over 40 P4P programs are known to focus on inpatient care alone, yet only eight peer-reviewed articles have assessed the effects of these programs on clinical quality, patient experience, safety, or resource use (Mehrotra et al. 2009). These studies have found some improvements in quality, but they also noted methodological problems in the assessments, which did not preclude the possibility that the improvements were due to temporal trends alone. Some of the largest assessments have found no significant improvements in quality (Lindenauer et al. 2007). Most remarkable, however, is that not a single one of these studies has reported data on the impact of these emerging P4P programs on equity (closing racial, ethnic, linguistic, and other socioeconomic gaps in health status), which is one of the six key dimensions of quality identified by the Institute of Medicine (Institute of Medicine Committee on Quality of Health Care in America 2001). This lack of investigation is especially striking because the potential for P4P programs to create unintended adverse consequences on equity is a well-recognized concern. Indeed, the lack of evidence regarding likely hazards of performance incentive programs for vulnerable populations and providers that care for them, such as safety net hospitals, has been a focus of particular concern and discussion for some time (Chien et al. 2007). Commentators have outlined several potential mechanisms through which P4P could worsen health disparities—including the creation of incentives for providers to avoid patients perceived to be more likely to have low-quality scores (cherry picking), the promotion of one-size-fits-all quality improvement initiatives that may be less effective for racial or ethnic minority groups or for patients with limited health literacy, and the widening of the resource gap for providers who care for these populations. Yet empirical research in this area is lagging. The lack of research is driven, in part, by the lack of data. Chien et al.'s (2007) search of the published literature from 1996 to 2006 led to 41,974 articles related to performance incentive programs, but only 536 of these articles contained any information about patient race and ethnicity. After excluding studies that were not empirical, not in English, and that were conducted outside the United States, they found a single research article on the impact of a public reporting, not P4P program, on disparities (Werner, Asch, and Polsky 2005). A more recent evaluation of the impact of a large P4P initiative on ethnic disparities in coronary heart disease management in the United Kingdom found improvements in quality measures across ethnic groups, but it was associated with reductions in disparities for only 2 of the 10 quality indicators (Millett et al. 2009). In light of continuing problems of rising costs, mediocre quality, and, therefore, relatively poor value for the money spent on health care in the United States, most commentators believe efforts to link payments more closely to providers' results on health care quality measures will be a key component of U. S. health care reform strategies. Health services researchers need to be informing these efforts and the design of these programs. To do so, however, we will need to address several critical knowledge gaps. Linking performance incentive programs to quality requires that we ask, How broadly or narrowly do we envision and define the dimensions of quality? Can we develop measures of quality that explicitly address the domain of equity? And, in developing standard measures in the various domains of quality, what is our understanding of the association between these measures and health outcomes? Key proposals to address these issues include the recent development of quality measures that are intended to directly target disparity reduction, along with the design of some P4P programs to reward quality improvement in addition to the achievement of high benchmark levels of quality (Casalino et al. 2007; Chien and Chin 2009). Here, we highlight pressing gaps in the literature and propose a set of priorities for health services researchers to advance the field of quality measurement and facilitate development of more comprehensive and effective performance incentive programs.

In this paper, nebulized or intravenous cetuximab (also known as Erbitux) labeled with NIR dyes is administered in the lungs of the mouse and imaged using a time-domain fluorescence imaging system (Optix (R) ). Time resolved measurements provide lifetime of the fluorescent probes. In addition, through time-of-flight information contained in the data, one can also assess probe localization and concentration distribution quantitatively. Results shown include suppression of tissue autofluorescence by lifetime gating and recovery of targeted and non-targeted distributions of cetuximab labeled with the NIR fluorophores.

Over the last decade, there has been increased attention to the role of earlier HIV testing in the United States. Our objective was to determine if this has translated into changes in the proportion of inpatients with advanced disease at the time of initial HIV diagnosis. We identified inpatients discharged with a new diagnosis of HIV infection or AIDS between 1994 and 2004 at two academic medical centers. We examined trends in initial CD4 count at diagnosis over three time periods: 1994-1996, 1997-2000 and 2001-2004. Between 1994 and 2004, 235 inpatients were newly diagnosed with HIV infection or AIDS in the two centers. For the 217 patients with available CD4 count data, the median initial CD4 count was 41/microl (interquartile range 19-138/microl). Of the 217 patients, 184(85%) had CD4or =200/microl and 119/217 (55%) had CD4or =50/microl. There were no significant differences in median CD4 count by time period. A large majority of inpatients with newly diagnosed HIV infection at two academic medical centers between 1994 and 2004 had signs of advanced immunodeficiency. Over this recent 11-year period there was no evidence that inpatients with a new HIV diagnosis were identified at earlier stages of disease.

In order to precisely recover fluorescence lifetimes from bulk tissues, one needs to employ complex light propagation models (e.g., the radiative transfer equation or a simpler yet consistent approximation, the diffusion equation) requiring knowledge of the tissue optical properties. This can be computationally expensive and therefore not practical in many applications. We present a novel method to estimate the fluorescence lifetimes of multiple fluorophores embedded in mice. By assuming that the photon diffusion does not significantly change the fluorescence decay slope, the light propagation is simply modeled as a time-delay during lifetime estimation. Applications of this approach are demonstrated by simulation, phantom data, and in vivo experiments.