Narrative comments about pediatric inpatient experiences yield substantial information beyond answers to closed-ended CAHPS survey questions.

PURPOSE: Adults' comments on patient experience surveys explain variation in provider ratings, with negative comments providing more actionable information than positive comments. We investigate if narrative comments on the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey of inpatient pediatric care (Child HCAHPS) account for global perceptions of the hospital beyond that explained by reports about specific aspects of care. METHODS: We analyzed 545 comments from 927 Child HCAHPS surveys completed by parents and guardians of hospitalized children with at least a 24-h hospital stay from July 2017 to December 2020 at an urban children's hospital. Comments were coded for valence (positive/negative/mixed) and actionability and used to predict Overall Hospital Rating and Willingness to Recommend the Hospital along with Child HCAHPS composite scores. RESULTS: Comments were provided more often by White and more educated respondents. Negative comments and greater actionability of comments were significantly associated with Child HCAHPS global rating measures, controlling for responses to closed-ended questions, and child and respondent characteristics. Each explained an additional 8% of the variance in respondents' overall hospital ratings and an additional 5% in their willingness to recommend the hospital. CONCLUSIONS: Child HCAHPS narrative comment data provide significant additional information about what is important to parents and guardians during inpatient pediatric care beyond closed-ended composites. PRACTICE IMPLICATIONS: Quality improvement efforts should include a review of narrative comments alongside closed-ended responses to help identify ways to improve inpatient care experiences. To promote health equity, comments should be encouraged for racial-and-ethnic minority patients and those with less educational attainment.

Classifying patients with non-specific chronic low back pain using the impact stratification score in an online convenience sample.

BACKGROUND: In 2014, the National Institute of Health Pain Consortium's research task force (RTF) on research standards for chronic low back pain (CLBP) proposed the Impact Stratification Score (ISS) as a patient-reported outcome measure that could stratify patients by the impact CLBP has on their lives. This work compares three newly developed ISS-based classifications to the RTF's original to provide an optimal recommendation. METHODS: The online sample included 1226 individuals from Amazon's Mechanical Turk who indicated having non-specific CLBP, average age of 40, 49% female, and 67% White. Participants completed the PROMIS-29 v2.1 profile survey that contains the 9 ISS items as well the Roland-Morris Disability Questionnaire (RMDQ) and Graded Chronic Pain Scale (GCPS). Other items included high-impact chronic pain; not working due to health problems; overall health; and number of healthcare visits for back pain in the past 6 months. Three new classifications were created using quartiles (Classification 2), latent profile analysis (Classification 3), and one modeled after the GCPS (Classification 4). Classifications were subsequently compared to the RTF-proposed classification (Classification 1) on several concurrent and prognostic criteria. RESULTS: Classification 1 had three CLBP severity groups, four in Classification 2, three in Classification 3, and four in Classification 4. All novel classifications improved upon the original. Classification 2 performed best at minimizing the classification of those with negative outcomes into the lowest severity groups at baseline (e.g., 11% with RMDQ ≥ 7) and 6 months (e.g., 8.2% had fair/poor health). Classification 4 performed best at maximizing classification of those with negative outcomes into the most severe group concurrently (e.g., 100% had GCPS grade ≥ 2) and at 6 months (e.g., 100% with RMDQ ≥ 7). CONCLUSIONS: We developed three ISS-based classification schemes and tested them against several outcomes. All three improved upon the original scheme. While appearing more optimal than other classifications in the lowest severity groups, Classification 2 presents some considerations and limitations. Given that Classification 4 was an improvement at the lowest end of severity and was the best at the highest end, it is our tentative recommendation that this approach be adopted to classify individuals with non-specific CLBP.

Shadow Coaching Improves Patient Experience for English-Preferring Patients but not for Spanish-Preferring Patients.

BACKGROUND: Shadow coaching, a type of one-on-one provider counseling by trained peers, is an effective strategy for improving provider behaviors and patient interactions, but its effects on improving patient experience for English- and Spanish-preferring patients is unknown. OBJECTIVE: Assess effects of shadow coaching on patient experience for English- and for Spanish-preferring patients. DESIGN: We analyzed 2012-2019 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) data (n=46,089) from an urban Federally Qualified Health Center with 44 primary care practices and 320 providers. One-third (n=14,631) were Spanish-preferring patients. We fit mixed-effects regression models with random effects for provider (the level of treatment assignment) and fixed effects for time (a linear spline for time with a knot and "jump" at coaching date), patient characteristics, and site indicators, stratified by preferred language. PARTICIPANTS: The 74 providers who had a 6-month average top-box score on the CAHPS overall provider rating below 90 (on a 100-point scale) were shadow coached. Similar percentages of English-preferring (45%) and Spanish-preferring patients (43%) were seen by coached providers. INTERVENTION: Trained providers observed patient care by colleagues and provided suggestions for improvement. Verbal feedback was provided immediately after the observation and the participant received a written report summarizing the comments and recommendations from the coaching session. MAIN MEASURES: CG-CAHPS Visit Survey 2.0 provider communication composite and overall provider rating (0-100 scoring). KEY RESULTS: We found a statistically significant 2-point (small) jump in CAHPS provider communication and overall provider rating among English-preferring patients of coached providers. There was no evidence of a coaching effect on patient experience for Spanish-preferring patients. CONCLUSIONS: Coaching improved care experiences for English-preferring patients but may not have improved patient experience for Spanish-preferring patients. Selection and training of providers to communicate effectively with Spanish-preferring patients is needed to extend the benefits of shadow coaching to Spanish-preferring patients.

Evaluation of a protocol for eliciting narrative accounts of pediatric inpatient experiences of care.

OBJECTIVE: To evaluate the measurement properties of a set of six items designed to elicit narrative accounts of pediatric inpatient experience. DATA SOURCES: Data came from 163 participants recruited from a probability-based online panel of U.S. adults. Participants were family members of a child who had an overnight hospital stay in the past 12 months. STUDY DESIGN: Cross-sectional survey with follow-up phone interviews. DATA COLLECTION/EXTRACTION METHODS: Participants completed an online (n = 129) or phone (n = 34) survey about their child's hospitalization experience. The survey contained closed-ended items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) survey, followed by the six narrative items. Approximately 2 weeks after completing the survey, 47 participants additionally completed a one-hour, semi-structured phone interview, the results of which served as a "gold standard" for evaluating the fidelity of narrative responses. Qualitative content analysis was used to code narrative and interview responses for domains of patient experience and actionability. PRINCIPAL FINDINGS: The average narrative was 248 words (SD = 319). Seventy-nine percent of narratives mentioned a topic included in the Child HCAHPS survey; 89% mentioned a topic not covered by that survey; and 75% included at least one detailed description of an actionable event. Overall, there was 66% correspondence between narrative and interview responses. Correspondence was higher on the phone than in the online condition (75% vs. 59%). CONCLUSIONS: Narratives elicited from rigorously designed multi-item sets can provide detailed, substantive information about pediatric inpatient experiences that hospitals could use to improve child and family experiences during pediatric hospitalization. They add context to closed-ended survey item responses and provide information about experiences of care important to children and families that are not included in quantitative surveys.

Follow-Up Shadow Coaching Improves Primary Care Provider-Patient Interactions and Maintains Improvements When Conducted Regularly: A Spline Model Analysis.

INTRODUCTION: Shadow coaching improves provider-patient interactions, as measured by CG-CAHPS® overall provider rating (OPR) and provider communication (PC). However, these improvements erode over time. AIM: Examine whether a second coaching session (re-coaching) improves and sustains patient experience. SETTING: Large, urban Federally Qualified Health Center PROGRAM: Trained providers observed patient care by colleagues and provided suggestions for improvement. Providers with OPRs<90 (0-100-point scale) were eligible. EVALUATION: We used stratified randomization based on provider type and OPR to assign half of the 40 eligible providers to re-coaching. For OPR and PC, we fit mixed-effects regression models with random-effects for provider (level of treatment assignment) and fixed-effects for time (linear spline with knots and possible "jump" at initial coaching and re-coaching), previous OPR, patient characteristics, and sites. We observed a statistically significant medium jump among re-coached providers after re-coaching on OPR (3.7 points) and PC (3.5 points); differences of 1, 3, and ≥5-points for CAHPS measures are considered small, medium, and large. Improvements from re-coaching persisted for 12 months for OPR and 8 months for PC. DISCUSSION: Re-coaching improved patient experience more than initial coaching, suggesting the reactivation of knowledge from initial coaching. However, re-coaching gains also eroded. Coaching should occur every 6 to 12 months to maintain behaviors and scores.

A Simple Method for Simulating Dementia Onset and Death within an Existing Demographic Model.

BACKGROUND: Dementia is a common disease that has an impact on both the affected individual and family members who provide caregiving. Simulation models can assist in setting policy that anticipates public health needs by predicting the demand for and availability of care. OBJECTIVE: We developed a relatively simple method for simulating the onset of dementia that can be used in combination with an existing microsimulation model. METHODS: We started with Socsim, a demographic microsimulation model that simulates a population with family kinship networks. We simulated dementia in the Socsim population by simulating the number of individuals diagnosed with dementia in their lifetime and the ages of onset and death from dementia for each of these dementia cases. We then matched dementia cases to the simulated population based on age at death, so for each individual, we simulate whether they develop dementia and, if so, their age at onset. This approach simulates dementia onset but does not alter the demographic model's simulated age of death. RESULTS: We selected model dementia parameters so that the combined Socsim-Dementia model reproduces published dementia prevalence rates and survival times after diagnosis. CONCLUSIONS: Adding simulation of dementia to a kinship network model enables prediction of the availability of family caregivers for people with dementia under a range of different assumptions about future fertility, mortality, and dementia risk. We demonstrated how to add simulation of dementia onset and death to an existing microsimulation model to obtain a method for predicting dementia prevalence in the context of another more detailed model. The approach we developed can be generalized to simulate other progressive health conditions that affect mortality.

Shadow Coaching Improves Patient Experience With Care, But Gains Erode Later.

BACKGROUND: Health care organizations strive to improve patient care experiences. Some use one-on-one provider counseling (shadow coaching) to identify and target modifiable provider behaviors. OBJECTIVE: We examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban Federally Qualified Health Center. RESEARCH DESIGN: Seventy-four providers with "medium" (ie, slightly below average) overall provider ratings received coaching and were compared with 246 uncoached providers. We fit mixed-effects regression models with random effects for provider (level of treatment assignment) and fixed effects for time (linear spline with a knot and "jump" at coaching date), patient characteristics and site indicators. By design, coached providers performed worse at selection; models account for the very small (0.2 point) regression-to-the-mean effects. We assessed differential effects by coach. SUBJECTS: A total of 46,452 patients (from 320 providers) who completed the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Visit Survey 2.0. MEASURES: CAHPS overall provider rating and provider communication composite (scaled 0-100). RESULTS: Providers not chosen for coaching had a nonsignificant change in performance during the period when selected providers were coached. We observed a statistically significant 2-point (small-to-medium) jump among coached providers after coaching on the CAHPS overall provider rating and provider communication score. However, these gains disappeared after 2.5 years; effects differed by coach. CONCLUSIONS: Shadow coaching improved providers' overall performance and communication immediately after being coached. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed.

Provider and coach perspectives on implementing shadow coaching to improve provider-patient interactions.

BACKGROUND: Healthcare organizations want to improve patient care experiences. Some use 'shadow coaching' to improve interactions between providers and patients. A Federally Qualified Health Center (FQHC) implemented a half-day observation of individual primary-care providers by a 'shadow coach' during real-time patient visits, including an in-person verbal debrief afterwards and a written report with specific recommendations. Shadow coaching identified areas for improvement. We aimed to characterize lessons and barriers to implementing shadow coaching as a mechanism to improve interactions with patients and change organizational culture. METHODS: We examined provider and coach perceptions of shadow coaching through interviewing coached providers, stratified by provider type and Consumer Assessment of Healthcare Providers and Systems (CAHPS) performance, and the coaches who coached the most providers. We interviewed 19 coached providers and 2 coaches in a large, urban FQHC. Content analysis identified implementation barriers, facilitators and themes. RESULTS: Coaches reported needing 'buy-in' throughout the organization and the need to be credible and empathize with the providers being coached. Most providers reported behaviour changes based on recommendations. Almost all providers recalled at least one coaching recommendation that was actionable. Providers and coaches highlighted patient-level and practise-level barriers that impeded their ability to implement recommended improvements. CAHPS data was reported as an effective performance management metric for measuring change, counselling providers, and evaluating provider-level efforts but was not always specific enough to yield tangible recommendations. CONCLUSIONS: Regular messaging by leadership about the priority and purpose of shadow coaching was essential for both physician engagement and its mature implementation across the organization. Coaching could be embedded into a long-term strategy of professional development with periodic re-coaching. Re-coaching sessions could target issues raised by providers, such as dealing with difficult patients or specific populations. Research on the timing and content of re-coaching is needed.

Assessing the Significance of Individual Change in 2 Samples of Patients in Treatment for Low Back Pain Using 5 Different Statistical Indicators.

OBJECTIVE: The purpose of this study was to estimate the significance of individual change using 5 statistical indicators in 2 samples of patients treated for low back pain. METHODS: This secondary analysis used observational and clinical trial data from 2 samples of patients with low back pain to compare 5 ways of estimating significant individual change on the Impact Stratification Score (ISS) administered at the following 2 time points: 3 months apart in an observational study of 1680 patients undergoing chiropractic care, and 6 weeks apart in a randomized trial of 750 active-duty military personnel with low back pain. The following 5 methods were compared: (1) standard deviation index; (2) standard error of measurement (SEM); (3) standard error of estimate (SEE); (4) standard error of prediction (SEP); and (5) the reliable change index (RCI). The ISS is the sum of the Patient-Reported Outcomes Measurement Information System (PROMIS)-29 v2.1 physical function, pain interference, and pain intensity scores and is scored to have a possible range of 8 (least impact) to 50 (greatest impact). RESULTS: The amount of change on the ISS needed for significant individual change in both samples was 5 for the SEM and for the SEE and 7 for the SEP and RCI. CONCLUSIONS: The results of the current study provide some preliminary support for use of the SEP or the RCI to identify significant individual change and provide estimated thresholds of individual change that can be used for the ISS. The SEP and RCI estimates of significant change were consistent with retrospective ratings of change of at least moderately better in prior research. These 2 were less likely than other methods to classify people with low back pain as responders who have not actually gotten better (false positive). In contrast, the SEM and SEE were less likely to miss real change (false negative).

The Foreclosure Crisis, Community Change, and the Cognitive Health of Older Adults.

OBJECTIVES: While home foreclosures are often thought of as a household-level event, the consequences may be far-reaching, and spill over to the broader community. Older adults, in particular, could be affected by the spiral of community changes that result from foreclosures, but we know very little about how the foreclosure crisis is related to older adult health, in particular cognition. METHOD: This article uses growth curve models and data from the Health and Retirement Study matched to Census and county-level foreclosure data to examine whether community foreclosures are related to older adults' cognitive health and the mechanisms responsible. RESULTS: We find that higher rates of county-level foreclosures are associated with a faster decline in individual cognition at older ages. Although we examined an extensive number of individual and community mechanisms, including individual housing wealth and depressive symptoms, community structural factors, social factors, and perceptions of physical disorder and cohesion, none of the mechanisms examined here explained this relationship. DISCUSSION: This study shows that the adverse consequences of home foreclosures spill over to the local community, with implications for the cognitive health of older adults.

What influences evidence-based treatment sustainment after implementation support ends? A mixed method study of the adolescent-community reinforcement approach.

BACKGROUND: Little is known about clinician perspectives regarding the factors that support or hinder the long-term delivery (i.e., sustainment) of evidence-based treatments in community-based treatment settings. METHODS: Clinical staff from 82 community-based treatment organizations that received federal grant funding to support the delivery of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment for adolescent substance use, were asked to participate in interviews focused on understanding their perspectives about the sustainment of A-CRA. Qualitative themes were identified using inductive and deductive approaches. Then the themes were dichotomized (present/absent) so that quantitative comparisons could be made between staff from organizations that sustained and did not sustain delivery of A-CRA. Administrative data about each organization in relation to federal funding support and their primary focus was also examined to explore whether these characteristics were associated with A-CRA sustainment. RESULTS: Staff (n = 134) representing 78 organizations participated in the interviews. Staff from organizations that had received multiple federal grants to support the delivery of A-CRA and whose primary focus was substance use rather than other conditions (mental health or primary care) were more likely to report sustaining A-CRA. Staff from sustaining organizations were more likely to report positive grant experiences and success with maintaining both organizational and external support in comparison to staff from non-sustaining organizations. Staff from non-sustaining organizations were more likely to report barriers to sustaining A-CRA, including more challenges with intervention delivery, and lack of internal support and external funding. CONCLUSIONS: Our findings lend empirical support for implementation theories in that multiple factors appear to be associated with long-term delivery of an evidence-based treatment. Although A-CRA was generally perceived positively by staff from both organizations that sustained A-CRA and organizations that did not sustain A-CRA, inner setting factors (e.g., structural policies, leadership support and staff retention) along with outer setting factors (e.g., external funding support) were reported as key to A-CRA sustainment.

A Cluster-Randomized Trial of Getting To Outcomes' Impact on Sexual Health Outcomes in Community-Based Settings.

The USA has high teen pregnancy rates compared to other developed nations. Many community-based organizations need assistance conducting evidence-based teen pregnancy prevention programs (EBPs) appropriately. This study evaluated the impact of an implementation support intervention called Getting To Outcomes (GTO) designed to help such organizations. This cluster randomized controlled trial compared 16 Boys and Girls Clubs (BGCs) implementing a teen pregnancy prevention EBP called Making Proud Choices for two years, with 16 BGCs implementing MPC augmented with GTO training, tools, and technical assistance. Participating middle school youth were compared on proximal outcomes (knowledge, attitudes, and intentions about sex and condoms from baseline to post) and sexual behaviors (frequency of sex and condom use, from baseline to 6-month follow-up). In year 1, there were no significant effects of GTO for any proximal outcome. After GTO-stimulated quality improvement in year 2, the GTO group improved significantly more on condom attitudes and use intentions. Frequency of sex and condom use did not differ between the two groups in either year; however, base rates of these behaviors in the sample were very low. Findings suggest that in typical community-based settings, detailed manuals and training common to structured EBPs may be sufficient to yield some improvement in key proximal outcomes, but that more systematic implementation support is needed to achieve greater improvement in these outcomes. Using GTO with many communities, as currently supported by various federal agencies, could yield public health impact via improvements in condom attitudes and use intentions.

Measuring sustainment of an evidence based treatment for adolescent substance use.

BACKGROUND: Measuring the extent a behavioral treatment is sustained in usual care practice settings after initial support for implementation ends is challenging. Oftentimes dichotomous self-report measures are used to measure health program sustainment, but these measures may not adequately capture the quality or extent of behavioral treatment delivery. Using data collected from community based organizations that received support to implement the Adolescent Community Reinforcement Approach (A-CRA), a measure of the extent of sustainment was derived. METHODS: Based on implementation theories and implementation support protocols, a total of 10 core treatment elements were identified to measure the extent of sustainment using information collected from key clinical staff. Item response theory (IRT) and principal component analyses (PCA) were used to further refine the 10 elements into composite measures of sustainment. The association between the 10 elements and the relationships between the comprehensive measures to a dichotomous sustainment measure were also examined. RESULTS: Results from PCA identified two components from the initial 10 elements for measuring the extent of A-CRA treatment sustainment. The two components described different aspects of organizational support for A-CRA treatment implementation, one representing the quality or extent of treatment staffing and delivery and the other representing the quality of or extent of clinical supervision. CONCLUSIONS: Using IRT and PCA, we were able to derive components that could be used to measure the extent of EBT sustainment and also better capture the quality of treatment delivery than the use of simple dichotomous measure. The methodological contribution of our study is that we have demonstrated a general analytic approach that may be applicable for other psychosocial treatments.

Factors associated with an evidence-based measure of implementation for the Adolescent Community Reinforcement Approach.

BACKGROUND: An evidence-based measure of implementation (EBMI) is an implementation outcome measure shown to have predictive validity with one or more future-measured constructs of importance. The current study sought to identify correlates and predictors of an EBMI called procedure exposure. Garner et al. (2016) found procedure exposure to be an EBMI for the Adolescent Community Reinforcement Approach (A-CRA). METHODS: The dataset included 76 community-based substance use treatment organizations located across the United States. Organizational-level regression analyses, which were framed within the context of Chaudoir et al. (2013) framework for predicting implementation outcomes, were used to examine predictors of A-CRA procedure exposure RESULTS: The Washington Circle's treatment initiation performance measure (B=5.05 [SE=1.60], p=0.002), as well as session exposure (B=0.18 [SE=0.06], p=0.003), were significant predictors of A-CRA procedure exposure in the backward stepwise regression analysis (Adjusted R-square=0.55). The Washington Circle's treatment engagement performance measure (B=7.93 [SE=0.77], p<0.001), as well as time-to-proficiency (B=-0.04 [SE=0.02], p=0.02), each had significant bivariate relationships with A-CRA procedure exposure but were not retained in the final model. CONCLUSIONS: Organizations implementing A-CRA are encouraged to make the following high priorities: (a) scheduling and completing a subsequent treatment session within 14days of their index session (treatment initiation) and (b) providing a targeted number of treatment sessions to each client (session exposure). To the extent organizations do this, they may be more likely to achieve higher levels of A-CRA procedure exposure.

Predicting evidence-based treatment sustainment: results from a longitudinal study of the Adolescent-Community Reinforcement Approach.

BACKGROUND: Implementation support models are increasingly being used to enhance the delivery of evidence-based treatments (EBTs) in routine care settings. Little is known about the extent to which these models lead to continued EBT use after implementation support ends. Moreover, few empirical studies longitudinally examine the hypothesized factors associated with long-term psychosocial EBT use (i.e., sustainment). In an effort to address this gap, the current study examined sustainment of an EBT called the Adolescent-Community Reinforcement Approach (A-CRA) following the end of implementation support. METHODS: Between 2006 and 2010, the Substance Abuse and Mental Health Services Administration awarded 3 years of A-CRA implementation support to 82 community-based organizations around the USA. The extent to which A-CRA was sustained following grant end and the hypothesized factors associated with EBT sustainment were collected using both retrospective and prospective data. We examined the extent to which 10 core treatment elements of A-CRA were sustained and the associations between the extent of A-CRA sustainment and hypothesized factors using a pattern-mixture longitudinal modeling approach. RESULTS: Staff from 76 organizations participated in data collection for a 92.86% response rate. On average, about half of the 10 core treatment elements were sustained following the loss of implementation support. Factors that appeared most important to A-CRA sustainment included characteristics that were related to the outer setting (communication, funding, and partnerships), inner setting (political support, organizational capacity, and supervisor turnover rate), implementation support period (number of clinicians and supervisors certified and employed at support end and number of youth served), and staff perceptions of the intervention (implementation difficulty, relative advantage, and perceived success). CONCLUSIONS: Even with multiple years of implementation support, community-based organizations face challenges in sustaining EBT delivery over time. Consistent with implementation theories, multiple factors appear related with EBT sustainment, including the degree of implementation during the initial support period, as well as adequate funding, infrastructure support, and staff support following the end of funding.

Using Claims Data to Examine Hospital Readmission Risk in Patients With Schizophrenia and Comorbid Marijuana Use Disorders.

OBJECTIVE: Few epidemiologic studies have examined marijuana use disorder and repeated hospitalizations related to schizophrenia. To address this gap, this study examines time to readmission by indicators for recent marijuana use disorder in the presence of alcohol use disorder (AUD) and other drug use disorder. METHOD: Our sample consisted of 4,349 patients with a primary diagnosis of schizophrenia spectrum disorder (SSD) in 2005 in individually linked California Health Care Cost and Utilization Project (CA HCUP) data. Readmissions were assessed from 2005 to 2011. Predictors for readmission were examined using a stratified, recurrent-event, Cox proportional hazards model. Sensitivity analyses were conducted on patients readmitted in 2010 or 2011. RESULTS: We found that having marijuana use disorder or AUD alone within 90 days of initial hospitalization was associated with longer times until first readmission. A lower risk of readmission for those with recent marijuana use disorder persisted through the fifth readmission (hazard ratio [HR] = 0.92, 95% CI [0.85, 0.99]) but was not significant in the sixth or greater readmission nor in sensitivity analyses. SSD patients with recent other drug use disorder had an increased risk for a second to fifth readmission (HR = 1.13, 95% CI [1.06, 1.20]). Those with recent AUD had an increased risk for a sixth or greater readmission (HR = 1.15, 95% CI [1.07, 1.23]). Both of these results remained significant in the sensitivity analysis. CONCLUSIONS: We found that AUD and other drug use disorder increase readmission risk in patients with SSD after a first hospitalization, whereas marijuana use disorder does not appear to be associated with an increased risk for readmission.

Neighborhood age structure and cognitive function in a nationally-representative sample of older adults in the U.S.

Recent evidence suggests that living in a neighborhood with a greater percentage of older adults is associated with better individual health, including lower depression, better self-rated health, and a decreased risk of overall mortality. However, much of the work to date suffers from four limitations. First, none of the U.S.-based studies examine the association at the national level. Second, no studies have examined three important hypothesized mechanisms - neighborhood socioeconomic status and neighborhood social and physical characteristics - which are significantly correlated with both neighborhood age structure and health. Third, no U.S. study has longitudinally examined cognitive health trajectories. We build on this literature by examining nine years of nationally-representative data from the Health and Retirement Study (2002-2010) on men and women aged 51 and over linked with Census data to examine the relationship between the percentage of adults 65 and older in a neighborhood and individual cognitive health trajectories. Our results indicate that living in a neighborhood with a greater percentage of older adults is related to better individual cognition at baseline but we did not find any significant association with cognitive decline. We also explored potential mediators including neighborhood socioeconomic status, perceived neighborhood cohesion and perceived neighborhood physical disorder. We did not find evidence that neighborhood socioeconomic status explains this relationship; however, there is suggestive evidence that perceived cohesion and disorder may explain some of the association between age structure and cognition. Although more work is needed to identify the precise mechanisms, this work may suggest a potential contextual target for public health interventions to prevent cognitive impairment.

Can implementation support help community-based settings better deliver evidence-based sexual health promotion programs? A randomized trial of Getting To Outcomes®.

BACKGROUND: Research is needed to evaluate the impact of implementation support interventions over and above typical efforts by community settings to deploy evidence-based prevention programs. METHODS: Enhancing Quality Interventions Promoting Healthy Sexuality is a randomized controlled trial testing Getting To Outcomes (GTO), a 2-year implementation support intervention. It compares 16 Boys and Girls Club sites implementing Making Proud Choices (MPC, control group), a structured teen pregnancy prevention evidence-based program with 16 similar sites implementing MPC augmented with GTO (intervention group). All sites received training and manuals typical for MPC. GTO has its own manuals, training, and onsite technical assistance (TA) to help practitioners complete key programming practices specified by GTO. During the first year, TA providers helped the intervention group adopt, plan, and deliver MPC. This group then received training on the evaluation and quality improvement steps of GTO, including feedback reports summarizing their data, which were used in a TA-facilitated quality improvement process that yielded revised plans for the second MPC implementation. This paper presents results regarding GTO's impact on performance of the sites (i.e., how well key programming practices were carried out), fidelity of MPC implementation, and the relationship between amount of TA support, performance, and fidelity. Performance was measured using ratings made from a standardized, structured interview conducted with participating staff at all 32 Boys and Girls Clubs sites after the first and second years of MPC implementation. Multiple elements of fidelity (adherence, classroom delivery, dosage) were assessed at all sites by observer ratings and attendance logs. RESULTS: After 2 years, the intervention sites had higher ratings of performance, adherence, and classroom delivery (dosage remained similar). Higher performance predicted greater adherence in both years. CONCLUSIONS: These findings suggest that in typical community-based settings, manuals and training common to structured EBPs may be sufficient to yield low levels of performance and moderate levels of fidelity but that systematic implementation support is needed to achieve high levels of performance and fidelity. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01818791.

Associations between implementation characteristics and evidence-based practice sustainment: a study of the Adolescent Community Reinforcement Approach.

BACKGROUND: Few empirical studies longitudinally examine evidence-based practice (EBP) sustainment and the hypothesized factors that influence it. In an effort to address this gap, the current study examined sustainment of an EBP for adolescent substance use called the adolescent community reinforcement approach (A-CRA). METHODS: A-CRA sustainment was assessed via information collected as part of key informant interviews and surveys with clinical staff from community-based treatment organizations that had received federal funding to implement A-CRA. Administrative data from the funding period on implementation was also used. Using discrete-time survival analysis, we regressed A-CRA sustainment on several factors theorized to influence EBP sustainment. Factors examined included outer setting, inner setting, implementation quality during the funding period, and intervention-related characteristics. RESULTS: Overall, data from 83 % of the targeted sample of treatment organizations was collected. A-CRA sustainment was strongly related to the time since funding loss. Strong relationships were found between sustainment status and implementation quality during the funding period, agency focus, funding stability, and political support for the treatment along with staff perceptions of the treatment's complexity and implementation difficulty. CONCLUSIONS: Consistent with the Consolidated Framework for Implementation Research, the current study found several factors related to the outer setting (e.g., funding stability), inner setting (e.g., agency focus), implementation quality during the funding period (e.g., staff trained, clients served), and characteristics of the intervention (e.g., implementation complexity) to be associated with EBP sustainment. Future research is warranted to examine the extent to which these relationships are stable over time. Efforts to ensure that adequate implementation occurs during the initial implementation period and that adequate funding, infrastructure, and staff support following the ending of initial support are critical to a program's survival.

Neighbourhood racial/ethnic composition and segregation and trajectories of cognitive decline among US older adults.

BACKGROUND: The influence of the sociodemographic context of one's environment on cognitive ageing is not well understood. METHODS: We examined differences in cognitive trajectories according to the racial/ethnic characteristics of the residential environment. On the basis of 63 996 person-years of data from a nationally representative cohort of 6150 adults over the age of 50 years from the Health and Retirement Study, we used multivariate linear mixed models to determine the effect of neighbourhood racial/ethnic composition and county-level segregation on cognitive function and cognitive decline over a 10-year period. RESULTS: In models adjusting for individual demographic and health characteristics, Hispanic composition had a significant positive association with cognitive function (standardised ß=0.136, p<0.05) and moderate evidence of an association with greater cognitive decline (standardised ß=-0.014, p=0.09). Greater Hispanic-white segregation was associated with statistically significant higher cognitive function at baseline (standardised ß=0.099, p<0.001) and greater cognitive decline (standardised ß=-0.011, p<0.01). For a 20 percentage-point increase in Hispanic composition and segregation, the observed associations implied 1 and 1.25 additional years of cognitive ageing over 10 years, respectively. These effects did not differ by individual race/ethnicity and were not explained by neighbourhood socioeconomic status or neighbourhood selection. Black composition and black-white segregation did not have a significant influence on cognitive ageing. DISCUSSION: This study demonstrates disparities in the progression of cognitive ageing according to racial/ethnic characteristics of the neighbourhood environment.