Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial

BACKGROUND

Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes.

METHODS

This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete.

FINDINGS

Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo.

INTERPRETATION

In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults.

FUNDING

National Institutes of Health and the US Department of Veterans Affairs.

Post-acute sequelae of COVID-19 and longitudinal antibody levels in a community-based cohort

BACKGROUND

Coronavirus disease 2019 (COVID-19) infection invokes variable immune responses and poses a risk of post-acute sequelae SARS-CoV-2 infection (PASC) symptoms; however, most data on natural history are derived from patients with severe infection. Further data are needed among patients with mild infection, who comprise most cases.

METHODS

The Dallas Fort-Worth (DFW) COVID-19 Prevalence Study included 21,597 community-dwelling adults (ages 18-89) who underwent COVID-19 PCR and anti-nucleocapsid antibody testing between July 2020 and March 2021. We invited participants with positive COVID-19 results (cases) and a subset with negative results (controls), matched on age, sex, race/ethnicity, and ZIP code, to complete a follow-up questionnaire for PASC symptoms and repeat anti-nucleocapsid testing, and anti-spike antibody testing between July and December 2021.

RESULTS

Of 3,917 adults invited to participate, 2260 (57.7%) completed the questionnaire- 1150 cases and 1110 controls. Persistent symptoms were reported in 21.1% of cases, with the most common being shortness of breath, fatigue, and loss of taste or smell. Among 292 cases with asymptomatic infection, >15% reported new fatigue and 8-10% reported new loss of taste/smell, myalgias, or headache. Median anti-nucleocapsid levels in cases decreased from 3.5U to 0.7U over a median follow-up of 8.6 months. Anti-spike antibody levels at 6-7 months post-vaccination in cases were similar to that of controls.

CONCLUSIONS

More than 1 in 5 patients with COVID-19 infection, including those with mild infection, reported persistent symptoms during follow-up. Both nucleocapsid and spike protein antibody levels decreased within six months following a COVID-19 infection and vaccination.

Population-based correlates of COVID-19 infection: An analysis from the DFW COVID-19 prevalence study

BACKGROUND

COVID-19 has resulted in over 1 million deaths in the U.S. as of June 2022, with continued surges after vaccine availability. Information on related attitudes and behaviors are needed to inform public health strategies. We aimed to estimate the prevalence of COVID-19, risk factors of infection, and related attitudes and behaviors in a racially, ethnically, and socioeconomically diverse urban population.

METHODS

The DFW COVID-19 Prevalence Study Protocol 1 was conducted from July 2020 to March 2021 on a randomly selected sample of adults aged 18-89 years, living in Dallas or Tarrant Counties, Texas. Participants were asked to complete a 15-minute questionnaire and COVID-19 PCR and antibody testing. COVID-19 prevalence estimates were calculated with survey-weighted data.

RESULTS

Of 2969 adults who completed the questionnaire (7.4% weighted response), 1772 (53.9% weighted) completed COVID-19 testing. Overall, 11.5% of adults had evidence of COVID-19 infection, with a higher prevalence among Hispanic and non-Hispanic Black persons, essential workers, those in low-income neighborhoods, and those with lower education attainment compared to their counterparts. We observed differences in attitudes and behaviors by race and ethnicity, with non-Hispanic White persons being less likely to believe in the importance of mask wearing, and racial and ethnic minorities more likely to attend social gatherings.

CONCLUSION

Over 10% of an urban population was infected with COVID-19 early during the pandemic. Differences in attitudes and behaviors likely contribute to sociodemographic disparities in COVID-19 prevalence.

Effectiveness of an algorithm‐based care pathway for patients with non‐valvular atrial fibrillation presenting to the emergency department

Objective

Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence‐based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non‐valvular AF (EDAFMP) on hospital use and care process measures.

Methods

We deployed a voluntary‐use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous “usual care” controls, using a propensity‐score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non‐valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion.

Results

Preimplementation (January 1, 2016–December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017–June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29–0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46–0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, P < 0.001) and be referred to a cardiologist (93% vs 29%, P < 0.001) versus the comparator group.

Conclusion

EDAFMP use is associated with decreased hospital admission during an index ED encounter for non‐valvular AF, and improved delivery of AF care processes.

Association of Healthcare Access With Intensive Care Unit Utilization and Mortality in Patients of Hispanic Ethnicity Hospitalized With COVID-19

BACKGROUND

Racial and ethnic minority groups in the United States experience a disproportionate burden of COVID-19 deaths.

OBJECTIVE

To evaluate whether outcome differences between Hispanic and non-Hispanic COVID-19 hospitalized patients exist and, if so, to identify the main malleable contributing factors.

DESIGN, SETTING, PARTICIPANTS

Retrospective, cross-sectional, observational study of 6097 adult COVID-19 patients hospitalized within a single large healthcare system from March to November 2020.

EXPOSURES

Self-reported ethnicity and primary language.

MAIN OUTCOMES AND MEASURES

Clinical outcomes included intensive care unit (ICU) utilization and in-hospital death. We used age-adjusted odds ratios (OR) and multivariable analysis to evaluate the associations between ethnicity/language groups and outcomes.

RESULTS

32.1% of patients were Hispanic, 38.6% of whom reported a non-English primary language. Hispanic patients were less likely to be insured, have a primary care provider, and have accessed the healthcare system prior to the COVID-19 admission. After adjusting for age, Hispanic inpatients experienced higher ICU utilization (non-English-speaking: OR, 1.75; 95% CI, 1.47-2.08; English-speaking: OR, 1.13; 95% CI, 0.95-1.33) and higher mortality (non-English-speaking: OR, 1.43; 95% CI, 1.10-1.86; English-speaking: OR, 1.53; 95% CI, 1.19-1.98) compared to non-Hispanic inpatients. There were no observed treatment disparities among ethnic groups. After adjusting for age, Hispanic inpatients had elevated disease severity at admission (non-English-speaking: OR, 2.27; 95% CI, 1.89-2.72; English-speaking: OR, 1.33; 95% CI, 1.10- 1.61). In multivariable analysis, the associations between ethnicity/language and clinical outcomes decreased after considering baseline disease severity (P < .001).

CONCLUSION

The associations between ethnicity and clinical outcomes can be explained by elevated disease severity at admission and limited access to healthcare for Hispanic patients, especially non-English-speaking Hispanics.

Embedded Health Systems Science as a driver of care improvement within an integrated delivery organization

BACKGROUND

Embedded Health Systems Science (HSS) has the potential to reduce gaps between research and delivery of evidence-based medicine. Models are needed to guide the development of embedded HSS in health care delivery organizations particularly with the rise of value-based care.

METHODS

The development of HSS infrastructure at a large nonprofit health care delivery organization is described, along with an embedded HSS diabetes study to illustrate the integration of program specific data, electronic health records, and health care system data infrastructure. To compare diabetes outcomes across four evidenced-based programs, a control group was developed from EHR data using propensity score matching. Mixed effect adjusted models were used to estimate reductions in hemoglobin A1c (HbA1c) and body weight.

RESULTS

Adjusted analyses using an EHR derived comparison group demonstrated significantly different findings than unadjusted pre to post analyses. The embedded HSS study indicates that appropriate statistical methods, staff with required expertise, and integration with health system data infrastructure are needed to develop timely and rigorous HSS outcomes that effectively improve patient care.

CONCLUSIONS

Embedded HSS has the potential to inform value-based care models and contribute to evidence-based medicine approaches that improve patient care. Although developing system wide integrated data structures and staff with the appropriate skills requires substantial effort, the outcome is more reliable evaluations that lead to higher quality and higher value care.

IMPLICATIONS

Health care delivery organizations can improve patient care by dedicating resources to embed HSS into its routine operations.

Model for End-Stage Liver Disease-Lactate and Prediction of Inpatient Mortality in Patients With Chronic Liver Disease

BACKGROUND AND AIMS

Compared to other chronic diseases, patients with chronic liver disease (CLD) have significantly higher inpatient mortality; accurate models to predict inpatient mortality are lacking. Serum lactate (LA) may be elevated in patients with CLD due to both tissue hypoperfusion as well as decreased LA clearance. We hypothesized that a parsimonious model consisting of Model for End-Stage Liver Disease (MELD) and LA at admission may predict inpatient mortality in patients with CLD.

APPROACH AND RESULTS

We examined all patients with CLD in two large and diverse health care systems in Texas (North Texas [NTX] and Central Texas [CTX]) between 2010 and 2015. We developed (n = 3,588) and validated (n = 1,804) a model containing MELD and LA measured at the time of hospitalization. We further validated the model in a second cohort of 14 tertiary care hepatology centers that prospectively enrolled nonelective hospitalized patients with cirrhosis (n = 726). MELD-LA was an excellent predictor of inpatient mortality in development (concordance statistic [C-statistic] = 0.81, 95% confidence interval [CI] 0.79-0.82) and both validation cohorts (CTX cohort, C-statistic = 0.85, 95% CI 0.78-0.87; multicenter cohort C-statistic = 0.82, 95% CI 0.74-0.88). MELD-LA performed especially well in patients with specific cirrhosis diagnoses (C-statistic = 0.84, 95% CI 0.81-0.86) or sepsis (C-statistic = 0.80, 95% CI 0.78-0.82). For MELD score 25, inpatient mortality rates were 11.2% (LA = 1 mmol/L), 19.4% (LA = 3 mmol/L), 34.3% (LA = 5 mmol/L), and >50% (LA > 8 mmol/L). A linear increase (P < 0.01) was seen in MELD-LA and increasing number of organ failures. Overall, use of MELD-LA improved the risk prediction in 23.5% of patients compared to MELD alone.

CONCLUSIONS

MELD-LA (bswh.md/meldla) is an early and objective predictor of inpatient mortality and may serve as a model for risk assessment and guide therapeutic options.

182. Successes of a System-directed and Multi-faceted Inpatient Antimicrobial Stewardship Program in a Large, Integrated Delivery Organization

Background

In 2015, Baylor Scott and White Health (BSWH) implemented a system-wide antimicrobial stewardship program (ASP) across 22 acute care facilities. The ASP committee, led by an Infectious Diseases (ID) Physician and ID Pharmacist, includes membership of health system leadership, facility-specific ID physician and clinical pharmacy leaders, informatics, infection control, and microbiology. The committee’s purpose was to facilitate local implementation of antimicrobial stewardship interventions recommended by the Centers for Disease Control and Prevention and to improve antimicrobial use at BSWH.

Methods

The ASP created and approved antibiotic use guidelines (carbapenems, vancomycin, daptomycin, fluoroquinolones), policies, and set performance goals related to antibiotic use, which were then implemented locally at each facility. Beginning July 2016, all 22 acute care facilities went live with a clinical decision support (CDS) tool, a mobile device platform for physician access to ASP guidelines, and a requirement for antibiotic review at 48–72 hours. The CDS software also provided tracking of utilization data as days of therapy (DOT) standardized to 1,000 patient-days at risk (DAR) at the local facility and health system levels. The ASP committee tracked and reported metrics on the usage of total and targeted antibacterials, with comparisons in usage made between fiscal years (FY) 2017 and 2018. Means of total antibacterial usage and targeted antibiotics were compared between July to March of each FY using t-tests.

Results

Mean total antibacterial usage for the BSWH system was 649.6 vs. 622.6 DOT/1,000 DAR for FY17 and FY18, respectively (difference-Δ: 27.0; CI 95%: 7.9–46.1; P = 0.008). Mean targeted antibacterial usage (in DOT/1,000 DAR, FY17 vs. FY18) was 100.2 vs. 92.8 for vancomycin (Δ: 7.4; CI 95%: 5.0–9.9; P < 0.001), 30.4 vs. 20.7 for carbapenems (Δ: 9.7; CI 95%: 7.2–12.3; P < 0.001), 80.1 vs. 60.1 for fluoroquinolones (Δ: 20.0; CI 95%: 17.1–22.9; P < 0.001), and 4.6 vs. 4.4 for daptomycin (Δ: 0.2; CI 95%: -0.5–1.0; P = 0.454).

Conclusion

BSWH has made significant progress in reducing targeted and overall total antibacterial usage through the implementation of an enterprise-level antimicrobial stewardship program using a multifaceted approach.

Disclosures

All authors: No reported disclosures.

Increasing Health Care Burden of Chronic Liver Disease Compared With Other Chronic Diseases, 2004-2013

BACKGROUND & AIMS

Chronic liver disease (CLD) is a common and expensive condition, and studies of CLD-related hospitalizations have underestimated the true burden of disease. We analyzed data from a large, diverse health care system to compare time trends in CLD-related hospitalizations with those in congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD).

METHODS

We collected data from a large health care system in Texas on hospitalizations related to CLD (n = 27,783), CHF (n = 60,415), and COPD (n = 34,199) from January 1, 2004 through December 31, 2013. We calculated annual hospitalization rates (per 100,000) and compared hospital course, inpatient mortality, ancillary services, and readmissions.

RESULTS

Compared with patients with CHF (median age, 71 years) or COPD (median age, 69 years), patients with CLD were significantly younger (median age, 57 years) (P < .01 vs CHF and COPD). Higher proportions of patients with CLD were uninsured (11.7% vs 5.4% for CHF and 5.4% for COPD, P < .01) and Hispanic (17% for CLD vs 9.3% for CHF and 5.0% for COPD, P < .01). A lower proportion of patients with CLD had Medicare (41.5% vs 68.6% with CHF and 70.1% with COPD, P < .01). From 2004 through 2013, the rate of CLD-related hospitalization increased by 92% (from 1295/100,000 to 2490/100,000), compared with 6.7% for CHF (from 3843/100,000 to 4103/100,000) and 48.8% for COPD (from 1775/100,000 to 2642/100,000). During this time period, CLD-related hospitalizations covered by Medicare increased from 31.8% to 41.5%, whereas hospitalizations covered by Medicare did not change for CHF (remained at 70%) or COPD (remained at 70%). Patients with CLD had longer hospital stays (7.3 days vs 6.2 days for CHF and 5.9 days for COPD, P < .01). A higher proportion of patients with CLD died or were discharged to hospice (14.2% vs 11.5% of patients with CHF and 9.3% of patients with COPD, P < .01), and a smaller proportion had access to postacute care (13.2% vs 23.2% of patients with CHF and 27.4% of patients with COPD, P < .01). A higher proportion of patients with CLD were readmitted to the hospital within 30 days (25% vs 21.9% of patients with CHF and 20.6% with COPD, P < .01).

CONCLUSIONS

Patients with CLD, compared with selected other chronic diseases, had increasing rates of hospitalization, longer hospital stays, more readmissions, and, despite these adverse outcomes, less access to postacute care. Disease management models for CLD are greatly needed to manage the anticipated increase in hospitalizations for CLD.

Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation : Washington, DC, USA. 14-15 December 2015

A1 Introduction to the 8^th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health

David Chambers, Lisa Simpson

D1 Discussion forum: Population health D&I research

Felicia Hill-Briggs

D2 Discussion forum: Global health D&I research

Gila Neta, Cynthia Vinson

D3 Discussion forum: Precision medicine and D&I research

David Chambers

S1 Predictors of community therapists’ use of therapy techniques in a large public mental health system

Rinad Beidas, Steven Marcus, Gregory Aarons, Kimberly Hoagwood, Sonja Schoenwald, Arthur Evans, Matthew Hurford, Ronnie Rubin, Trevor Hadley, Frances Barg, Lucia Walsh, Danielle Adams, David Mandell

S2 Implementing brief cognitive behavioral therapy (CBT) in primary care: Clinicians' experiences from the field

Lindsey Martin, Joseph Mignogna, Juliette Mott, Natalie Hundt, Michael Kauth, Mark Kunik, Aanand Naik, Jeffrey Cully

S3 Clinician competence: Natural variation, factors affecting, and effect on patient outcomes

Alan McGuire, Dominique White, Tom Bartholomew, John McGrew, Lauren Luther, Angie Rollins, Michelle Salyers

S4 Exploring the multifaceted nature of sustainability in community-based prevention: A mixed-method approach

Brittany Cooper, Angie Funaiole

S5 Theory informed behavioral health integration in primary care: Mixed methods evaluation of the implementation of routine depression and alcohol screening and assessment

Julie Richards, Amy Lee, Gwen Lapham, Ryan Caldeiro, Paula Lozano, Tory Gildred, Carol Achtmeyer, Evette Ludman, Megan Addis, Larry Marx, Katharine Bradley

S6 Enhancing the evidence for specialty mental health probation through a hybrid efficacy and implementation study

Tonya VanDeinse, Amy Blank Wilson, Burgin Stacey, Byron Powell, Alicia Bunger, Gary Cuddeback

S7 Personalizing evidence-based child mental health care within a fiscally mandated policy reform

Miya Barnett, Nicole Stadnick, Lauren Brookman-Frazee, Anna Lau

S8 Leveraging an existing resource for technical assistance: Community-based supervisors in public mental health

Shannon Dorsey, Michael Pullmann

S9 SBIRT implementation for adolescents in urban federally qualified health centers: Implementation outcomes

Shannon Mitchell, Robert Schwartz, Arethusa Kirk, Kristi Dusek, Marla Oros, Colleen Hosler, Jan Gryczynski, Carolina Barbosa, Laura Dunlap, David Lounsbury, Kevin O'Grady, Barry Brown

S10 PANEL: Tailoring Implementation Strategies to Context - Expert recommendations for tailoring strategies to context

Laura Damschroder, Thomas Waltz, Byron Powell

S11 PANEL: Tailoring Implementation Strategies to Context - Extreme facilitation: Helping challenged healthcare settings implement complex programs

Mona Ritchie

S12 PANEL: Tailoring Implementation Strategies to Context - Using menu-based choice tasks to obtain expert recommendations for implementing three high-priority practices in the VA

Thomas Waltz

S13 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Siri, rate my therapist: Using technology to automate fidelity ratings of motivational interviewing

David Atkins, Zac E. Imel, Bo Xiao, Doğan Can, Panayiotis Georgiou, Shrikanth Narayanan

S14 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Identifying indicators of implementation quality for computer-based ratings

Cady Berkel, Carlos Gallo, Irwin Sandler, C. Hendricks Brown, Sharlene Wolchik, Anne Marie Mauricio

S15 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Improving implementation of behavioral interventions by monitoring emotion in spoken speech

Carlos Gallo, C. Hendricks Brown, Sanjay Mehrotra

S16 Scorecards and dashboards to assure data quality of health management information system (HMIS) using R

Dharmendra Chandurkar, Siddhartha Bora, Arup Das, Anand Tripathi, Niranjan Saggurti, Anita Raj

S17 A big data approach for discovering and implementing patient safety insights

Eric Hughes, Brian Jacobs, Eric Kirkendall

S18 Improving the efficacy of a depression registry for use in a collaborative care model

Danielle Loeb, Katy Trinkley, Michael Yang, Andrew Sprowell, Donald Nease

S19 Measurement feedback systems as a strategy to support implementation of measurement-based care in behavioral health

Aaron Lyon, Cara Lewis, Meredith Boyd, Abigail Melvin, Semret Nicodimos, Freda Liu, Nathanial Jungbluth

S20 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Common loop assay: Methods of supporting learning collaboratives

Allen Flynn

S21 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Innovating audit and feedback using message tailoring models for learning health systems

Zach Landis-Lewis

S22 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Implementation science and learning health systems: Connecting the dots

Anne Sales

S23 Facilitation activities of Critical Access Hospitals during TeamSTEPPS implementation

Jure Baloh, Marcia Ward, Xi Zhu

S24 Organizational and social context of federally qualified health centers and variation in maternal depression outcomes

Ian Bennett, Jurgen Unutzer, Johnny Mao, Enola Proctor, Mindy Vredevoogd, Ya-Fen Chan, Nathaniel Williams, Phillip Green

S25 Decision support to enhance treatment of hospitalized smokers: A randomized trial

Steven Bernstein, June-Marie Rosner, Michelle DeWitt, Jeanette Tetrault, James Dziura, Allen Hsiao, Scott Sussman, Patrick O’Connor, Benjamin Toll

S26 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A patient-centered approach to successful community transition after catastrophic injury

Michael Jones, Julie Gassaway

S27 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - Conducting PCOR to integrate mental health and cancer screening services in primary care

Jonathan Tobin

S28 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A comparative effectiveness trial of optimal patient-centered care for US trauma care systems

Douglas Zatzick

S29 Preferences for in-person communication among patients in a multi-center randomized study of in-person versus telephone communication of genetic test results for cancer susceptibility

Angela R Bradbury, Linda Patrick-Miller, Brian Egleston, Olufunmilayo I Olopade, Michael J Hall, Mary B Daly, Linda Fleisher, Generosa Grana, Pamela Ganschow, Dominique Fetzer, Amanda Brandt, Dana Farengo-Clark, Andrea Forman, Rikki S Gaber, Cassandra Gulden, Janice Horte, Jessica Long, Rachelle Lorenz Chambers, Terra Lucas, Shreshtha Madaan, Kristin Mattie, Danielle McKenna, Susan Montgomery, Sarah Nielsen, Jacquelyn Powers, Kim Rainey, Christina Rybak, Michelle Savage, Christina Seelaus, Jessica Stoll, Jill Stopfer, Shirley Yao and Susan Domchek

S30 Working towards de-implementation: A mixed methods study in breast cancer surveillance care

Erin Hahn, Corrine Munoz-Plaza, Jianjin Wang, Jazmine Garcia Delgadillo, Brian Mittman Michael Gould

S31Integrating evidence-based practices for increasing cancer screenings in safety-net primary care systems: A multiple case study using the consolidated framework for implementation research

Shuting (Lily) Liang, Michelle C. Kegler, Megan Cotter, Emily Phillips, April Hermstad, Rentonia Morton, Derrick Beasley, Jeremy Martinez, Kara Riehman

S32 Observations from implementing an mHealth intervention in an FQHC

David Gustafson, Lisa Marsch, Louise Mares, Andrew Quanbeck, Fiona McTavish, Helene McDowell, Randall Brown, Chantelle Thomas, Joseph Glass, Joseph Isham, Dhavan Shah

S33 A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol

Jane Liebschutz, Karen Lasser

S34 Implementing collaborative care for substance use disorders in primary care: Preliminary findings from the summit study

Katherine Watkins, Allison Ober, Sarah Hunter, Karen Lamp, Brett Ewing

S35 Sustaining a task-shifting strategy for blood pressure control in Ghana: A stakeholder analysis

Juliet Iwelunmor, Joyce Gyamfi, Sarah Blackstone, Nana Kofi Quakyi, Jacob Plange-Rhule, Gbenga Ogedegbe

S36 Contextual adaptation of the consolidated framework for implementation research (CFIR) in a tobacco cessation study in Vietnam

Pritika Kumar, Nancy Van Devanter, Nam Nguyen, Linh Nguyen, Trang Nguyen, Nguyet Phuong, Donna Shelley

S37 Evidence check: A knowledge brokering approach to systematic reviews for policy

Sian Rudge

S38 Using Evidence Synthesis to Strengthen Complex Health Systems in Low- and Middle-Income Countries

Etienne Langlois

S39 Does it matter: timeliness or accuracy of results? The choice of rapid reviews or systematic reviews to inform decision-making

Andrea Tricco

S40 Evaluation of the veterans choice program using lean six sigma at a VA medical center to identify benefits and overcome obstacles

Sherry Ball, Anne Lambert-Kerzner, Christine Sulc, Carol Simmons, Jeneen Shell-Boyd, Taryn Oestreich, Ashley O'Connor, Emily Neely, Marina McCreight, Amy Labebue, Doreen DiFiore, Diana Brostow, P. Michael Ho, David Aron

S41 The influence of local context on multi-stakeholder alliance quality improvement activities: A multiple case study

Jillian Harvey, Megan McHugh, Dennis Scanlon

S42 Increasing physical activity in early care and education: Sustainability via active garden education (SAGE)

Rebecca Lee, Erica Soltero, Nathan Parker, Lorna McNeill, Tracey Ledoux

S43 Marking a decade of policy implementation: The successes and continuing challenges of a provincial school food and nutrition policy in Canada

Jessie-Lee McIsaac, Kate MacLeod, Nicole Ata, Sherry Jarvis, Sara Kirk

S44 Use of research evidence among state legislators who prioritize mental health and substance abuse issues

Jonathan Purtle, Elizabeth Dodson, Ross Brownson

S45 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 1 designs

Brian Mittman, Geoffrey Curran

S46 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 2 designs

Geoffrey Curran

S47 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 3 designs

Jeffrey Pyne

S48 Linking team level implementation leadership and implementation climate to individual level attitudes, behaviors, and implementation outcomes

Gregory Aarons, Mark Ehrhart, Elisa Torres

S49 Pinpointing the specific elements of local context that matter most to implementation outcomes: Findings from qualitative comparative analysis in the RE-inspire study of VA acute stroke care

Edward Miech

S50 The GO score: A new context-sensitive instrument to measure group organization level for providing and improving care

Edward Miech

S51 A research network approach for boosting implementation and improvement

Kathleen Stevens, I.S.R.N. Steering Council

S52 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - The value of qualitative methods in implementation research

Alison Hamilton

S53 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Learning evaluation: The role of qualitative methods in dissemination and implementation research

Deborah Cohen

S54 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Qualitative methods in D&I research

Deborah Padgett

S55 PANEL: Maps & models: The promise of network science for clinical D&I - Hospital network of sharing patients with acute and chronic diseases in California

Alexandra Morshed

S56 PANEL: Maps & models: The promise of network science for clinical D&I - The use of social network analysis to identify dissemination targets and enhance D&I research study recruitment for pre-exposure prophylaxis for HIV (PrEP) among men who have sex with men

Rupa Patel

S57 PANEL: Maps & models: The promise of network science for clinical D&I - Network and organizational factors related to the adoption of patient navigation services among rural breast cancer care providers

Beth Prusaczyk

S58 A theory of de-implementation based on the theory of healthcare professionals’ behavior and intention (THPBI) and the becker model of unlearning

David C. Aron, Divya Gupta, Sherry Ball

S59 Observation of registered dietitian nutritionist-patient encounters by dietetic interns highlights low awareness and implementation of evidence-based nutrition practice guidelines

Rosa Hand, Jenica Abram, Taylor Wolfram

S60 Program sustainability action planning: Building capacity for program sustainability using the program sustainability assessment tool

Molly Hastings, Sarah Moreland-Russell

S61 A review of D&I study designs in published study protocols

Rachel Tabak, Alex Ramsey, Ana Baumann, Emily Kryzer, Katherine Montgomery, Ericka Lewis, Margaret Padek, Byron Powell, Ross Brownson

S62 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Model simulation techniques to estimate the cost of implementing foundational public health services

Cezar Brian Mamaril, Glen Mays, Keith Branham, Lava Timsina

S63 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Inter-organizational network effects on the implementation of public health services

Glen Mays, Rachel Hogg

S64 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Implementation fidelity, coalition functioning, and community prevention system transformation using communities that care

Abigail Fagan, Valerie Shapiro, Eric Brown

S65 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Expanding capacity for implementation of communities that care at scale using a web-based, video-assisted training system

Kevin Haggerty, David Hawkins

S66 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Effects of communities that care on reducing youth behavioral health problems

Sabrina Oesterle, David Hawkins, Richard Catalano

S68 When interventions end: the dynamics of intervention de-adoption and replacement

Virginia McKay, M. Margaret Dolcini, Lee Hoffer

S69 Results from next-d: can a disease specific health plan reduce incident diabetes development among a national sample of working-age adults with pre-diabetes?

Tannaz Moin, Jinnan Li, O. Kenrik Duru, Susan Ettner, Norman Turk, Charles Chan, Abigail Keckhafer, Robert Luchs, Sam Ho, Carol Mangione

S70 Implementing smoking cessation interventions in primary care settings (STOP): using the interactive systems framework

Peter Selby, Laurie Zawertailo, Nadia Minian, Dolly Balliunas, Rosa Dragonetti, Sarwar Hussain, Julia Lecce

S71 Testing the Getting To Outcomes implementation support intervention in prevention-oriented, community-based settings

Matthew Chinman, Joie Acosta, Patricia Ebener, Patrick S Malone, Mary Slaughter

S72 Examining the reach of a multi-component farmers’ market implementation approach among low-income consumers in an urban context

Darcy Freedman, Susan Flocke, Eunlye Lee, Kristen Matlack, Erika Trapl, Punam Ohri-Vachaspati, Morgan Taggart, Elaine Borawski

S73 Increasing implementation of evidence-based health promotion practices at large workplaces: The CEOs Challenge

Amanda Parrish, Jeffrey Harris, Marlana Kohn, Kristen Hammerback, Becca McMillan, Peggy Hannon

S74 A qualitative assessment of barriers to nutrition promotion and obesity prevention in childcare

Taren Swindle, Geoffrey Curran, Leanne Whiteside-Mansell, Wendy Ward

S75 Documenting institutionalization of a health communication intervention in African American churches

Cheryl Holt, Sheri Lou Santos, Erin Tagai, Mary Ann Scheirer, Roxanne Carter, Janice Bowie, Muhiuddin Haider, Jimmie Slade, Min Qi Wang

S76 Reduction in hospital utilization by underserved patients through use of a community-medical home

Andrew Masica, Gerald Ogola, Candice Berryman, Kathleen Richter

S77 Sustainability of evidence-based lay health advisor programs in African American communities: A mixed methods investigation of the National Witness Project

Rachel Shelton, Lina Jandorf, Deborah Erwin

S78 Predicting the long-term uninsured population and analyzing their gaps in physical access to healthcare in South Carolina

Khoa Truong

S79 Using an evidence-based parenting intervention in churches to prevent behavioral problems among Filipino youth: A randomized pilot study

Joyce R. Javier, Dean Coffey, Sheree M. Schrager, Lawrence Palinkas, Jeanne Miranda

S80 Sustainability of elementary school-based health centers in three health-disparate southern communities

Veda Johnson, Valerie Hutcherson, Ruth Ellis

S81 Childhood obesity prevention partnership in Louisville: creative opportunities to engage families in a multifaceted approach to obesity prevention

Anna Kharmats, Sandra Marshall-King, Monica LaPradd, Fannie Fonseca-Becker

S82 Improvements in cervical cancer prevention found after implementation of evidence-based Latina prevention care management program

Deanna Kepka, Julia Bodson, Echo Warner, Brynn Fowler

S83 The OneFlorida data trust: Achieving health equity through research & training capacity building

Elizabeth Shenkman, William Hogan, Folakami Odedina, Jessica De Leon, Monica Hooper, Olveen Carrasquillo, Renee Reams, Myra Hurt, Steven Smith, Jose Szapocznik, David Nelson, Prabir Mandal

S84 Disseminating and sustaining medical-legal partnerships: Shared value and social return on investment

James Teufel

CER Hub: An informatics platform for conducting comparative effectiveness research using multi-institutional, heterogeneous, electronic clinical data

OBJECTIVES

Comparative effectiveness research (CER) requires the capture and analysis of data from disparate sources, often from a variety of institutions with diverse electronic health record (EHR) implementations. In this paper we describe the CER Hub, a web-based informatics platform for developing and conducting research studies that combine comprehensive electronic clinical data from multiple health care organizations.

METHODS

The CER Hub platform implements a data processing pipeline that employs informatics standards for data representation and web-based tools for developing study-specific data processing applications, providing standardized access to the patient-centric electronic health record (EHR) across organizations.

RESULTS

The CER Hub is being used to conduct two CER studies utilizing data from six geographically distributed and demographically diverse health systems. These foundational studies address the effectiveness of medications for controlling asthma and the effectiveness of smoking cessation services delivered in primary care.

DISCUSSION

The CER Hub includes four key capabilities: the ability to process and analyze both free-text and coded clinical data in the EHR; a data processing environment supported by distributed data and study governance processes; a clinical data-interchange format for facilitating standardized extraction of clinical data from EHRs; and a library of shareable clinical data processing applications.

CONCLUSION

CER requires coordinated and scalable methods for extracting, aggregating, and analyzing complex, multi-institutional clinical data. By offering a range of informatics tools integrated into a framework for conducting studies using EHR data, the CER Hub provides a solution to the challenges of multi-institutional research using electronic medical record data.

Developing electronic data methods infrastructure to participate in collaborative research networks

Context:

Collaborative networks support the goals of a learning health system by sharing, aggregating, and analyzing data to facilitate identification of best practices care across delivery organizations. This case study describes the infrastructure and process developed by an integrated health delivery system to successfully prepare and submit a complex data set to a large national collaborative network.

Case Description:

We submitted four years of data for a diverse population of patients in specific clinical areas: diabetes, chronic heart failure, sepsis, and hip, knee, and spine. The most recent submission included 19 tables, more than 376,000 unique patients, and almost 5 million patient encounters. Data was extracted from multiple clinical and administrative systems.

Lessons Learned:

We found that a structured process with documentation was key to maintaining communication, timelines, and quality in a large-scale data submission to a national collaborative network. The three key components of this process were the experienced project team, documentation, and communication. We used a formal QA and feedback process to track and review data. Overall, the data submission was resource intensive and required an incremental approach to data quality.

Conclusion:

Participation in collaborative networks can be time and resource intense, however it can serve as a catalyst to increase the technical data available to the learning health system.

Rapid response team interventions for severe hyperkalemia: evaluation of a patient safety initiative

RATIONALE

This study evaluates outcomes and process measures associated with a rapid response team (RRT) intervention for patients with severe hyperkalemia.

STUDY POPULATION

Inpatients on medical-surgical floors (excluding dialysis or comfort care patients) at a 1000-bed tertiary hospital from 2005 to 2009 with severe hyperkalemia (defined as potassium [K(+)] ≥ 6.3 mEq/L).

METHODS

Retrospective administrative data and medical record review. Hyperkalemia incidence (based both on coding data and laboratory test results) was assessed, as was the association between hyperkalemia and mortality. Independent physician reviewers adjudicated selected cases for death directly attributable to hyperkalemia and potential for preventability with the RRT intervention. All 115 Baylor University Medical Center (Dallas, TX) cases receiving the RRT hyperkalemia intervention over a 12-month period (December 2006-December 2007) underwent in-depth process assessment.

RESULTS

Hyperkalemia occurred as a codable diagnosis in approximately 3.2% of all hospital discharges annually (5-year average of 42 000 discharges), and K(+) values ≥ 6.3 mEq/L were observed in 0.8% to 0.9% of all K(+) assays run by the laboratory in the months sampled. Deaths determined to be directly related to hyperkalemia and potentially preventable were rare, with a total of only 4 events during the study period (3 of these were in the pre-implementation phase), precluding statistical analysis on mortality related to the intervention. The RRT averaged 6 to 10 interventions for hyperkalemia monthly (representing 10% of all inpatient K(+) values ≥ 6.3 mEq/L). Mean initial K(+) level triggering the RRT cascade was 6.7 ± 0.3 mEq/L; average time from floor notification of critical K(+) level to bedside RRT arrival was 14.6 ± 12.1 minutes. Over 24 to 36 hours, K(+) declined 1.7 ± 1.1 mEq/L between patients' initial and final K(+) values (P < 0.001).

CONCLUSIONS

Hyperkalemia occurs frequently in inpatient settings. Rapid response team intervention for this condition facilitates timely correction of critical laboratory test results and consistent treatment through use of a standardized protocol. Benefit of the intervention on mortality could not be reliably demonstrated in this study due to event rarity and challenges with case ascertainment. Further research with a prospective, multi-site cluster design using electronic medical records and larger sample sizes could demonstrate which RRT hyperkalemia intervention components warrant widespread adoption.