Opioid and other drug use and drug-related mortality as indicators of Hepatitis C and Human Immunodeficiency Virus in Oklahoma.

OBJECTIVES: Outbreaks of injection drug use (IDU)-associated infections have become major public health concerns in the era of the opioid epidemic. This study aimed to (1) identify county-level characteristics associated with acute HCV infection and newly diagnosed IDU-associated HIV in Oklahoma and (2) develop a vulnerability index using these metrics. METHODS: This study employs a county-level ecological design to examine those diagnosed with acute or chronic HCV or newly diagnosed IDU-associated HIV. Poisson regression was used to estimate the association between indicators and the number of new infections in each county. Primary outcomes were acute HCV and newly diagnosed IDU-associated HIV. A sensitivity analysis included all HCV (acute and chronic) cases. Three models were run using variations of these outcomes. Stepwise backward Poisson regression predicted new infection rates and 95% confidence intervals for each county from the final multivariable model, which served as the metric for vulnerability scores. RESULTS: Predictors for HIV-IDU cases and acute HCV cases differed. The percentage of the county population aged 18-24 years with less than a high school education and population density were predictive of new HIV-IDU cases, whereas the percentage of the population that was male, white, Pacific Islander, two or more races, and people aged 18-24 years with less than a high school education were predictors of acute HCV infection. Counties with the highest predicted rates of HIV-IDU tended to be located in central Oklahoma and have higher population density than the counties with the highest predicted rates of acute HCV infection. CONCLUSIONS: There is high variability in county-level factors predictive of new IDU-associated HIV infection and acute HCV infection, suggesting that different public health interventions need to be tailored to these two case populations.

Performance of infectious diseases specialists, hospitalists, and other internal medicine physicians in antimicrobial case-based scenarios: Potential impact of antimicrobial stewardship programs at 16 Veterans' Affairs medical centers.

OBJECTIVE: As part of a project to implement antimicrobial dashboards at select facilities, we assessed physician attitudes and knowledge regarding antibiotic prescribing. DESIGN: An online survey explored attitudes toward antimicrobial use and assessed respondents' management of four clinical scenarios: cellulitis, community-acquired pneumonia, non-catheter-associated asymptomatic bacteriuria, and catheter-associated asymptomatic bacteriuria. SETTING: This study was conducted across 16 Veterans' Affairs (VA) medical centers in 2017. PARTICIPANTS: Physicians working in inpatient settings specializing in infectious diseases (ID), hospital medicine, and non-ID/hospitalist internal medicine. METHODS: Scenario responses were scored by assigning +1 for answers most consistent with guidelines, 0 for less guideline-concordant but acceptable answers and -1 for guideline-discordant answers. Scores were normalized to 100% guideline concordant to 100% guideline discordant across all questions within a scenario, and mean scores were calculated across respondents by specialty. Differences in mean score per scenario were tested using analysis of variance (ANOVA). RESULTS: Overall, 139 physicians completed the survey (19 ID physicians, 62 hospitalists, and 58 other internists). Attitudes were similar across the 3 groups. We detected a significant difference in cellulitis scenario scores (concordance: ID physicians, 76%; hospitalists, 58%; other internists, 52%; P = .0087). Scores were numerically but not significantly different across groups for community-acquired pneumonia (concordance: ID physicians, 75%; hospitalists, 60%; other internists, 56%; P = .0914), for non-catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 65%; hospitalists, 55%; other internists, 40%; P = .322), and for catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 27% concordant; hospitalists, 8% discordant; other internists 13% discordant; P = .12). CONCLUSIONS: Significant differences in performance regarding management of cellulitis and low overall performance regarding asymptomatic bacteriuria point to these conditions as being potentially high-yield targets for stewardship interventions.

Facilitators and Barriers to Implementation of Lung Cancer Screening: A Framework-Driven Systematic Review.

BACKGROUND: The purpose of this study is to undertake a comprehensive systematic review to describe multilevel factors (barriers and facilitators) that may influence the implementation of low-dose chest computed tomography for lung cancer screening in the United States. METHODS: Systematic literature searches were performed using 6 online databases and citation indexes for peer-reviewed studies, for articles published from 2013 to 2021. Studies were classified into 3 perspectives, based on the study's unit of analysis: system, health-care provider, and patient. Barriers and facilitators identified for each study included in our final review were then coded and categorized using the Consolidate Framework for Implementation Research domains. RESULTS: At the system level, the 2 most common constructs were external policy and incentives and executing the implementation process. At the provider level, the most common constructs were evidence strength and quality of the intervention characteristics, patient needs and resources, implementation climate, and an individual's knowledge and beliefs about the intervention. At the patient level, the most common constructs were patient needs and resources, individual's knowledge and beliefs about the intervention, and engaging in the implementation process. These constructs can act as facilitators or barriers to lung cancer screening implementation. CONCLUSIONS: Applying the Consolidate Framework for Implementation Research domains and constructs to understand and specify factors facilitating uptake of lung cancer screening as well as cataloging the lessons learned from previous efforts helps inform the development and implementation processes of lung cancer screening programs in the community setting. REGISTRATION: PROSPERO, CRD42021247677.

Impact of the Oklahoma IDeA Network of Biomedical Research Excellence research support and mentoring program for early-stage faculty.

The Oklahoma IDeA Network of Biomedical Research Excellence (OK-INBRE) provides a formalized mentoring program and grant awards to new and early-stage faculty throughout Oklahoma. The OK-INBRE Research Project Investigator (RPI) award program has supported 30 faculty from both research-intensive universities and primarily undergraduate institutions (PUIs) over the past 15 yr. To examine the impact of this program, we assessed the career trajectory of OK-INBRE RPI awardees and compared their productivity with a control group of applicants who applied for but did not receive an RPI award. A mixed-methods approach was employed to assess longitudinal programmatic impact. Regression analyses were conducted to estimate the effect of an RPI award on faculty productivity, controlling for institutional affiliation. Key informant interviews were conducted to capture qualitative information about satisfaction and additional outcomes. OK-INBRE RPI awardees had a higher number in total and mean number of publications. In achieving extramural funding, RPI awardees were 12.5 times (P = 0.005) as likely to receive a grant award of any type and 4.5 times (P = 0.06) as likely to receive a subsequent federal grant as those in the control group. Many RPI awardees attributed their career success to OK-INBRE, but they also helped to identify barriers to advancement or productivity associated with their specific home institutions. The combined data indicate that OK-INBRE plays a significant role in launching new and early-stage investigators on a path toward independent research careers, which will in turn have a positive impact on the future of the biomedical research enterprise in Oklahoma.NEW & NOTEWORTHY The Oklahoma IDeA Network of Biomedical Research Excellence (OK-INBRE) has been offering a formalized mentoring program and grant awards to new and early-stage faculty throughout Oklahoma for the past 15 yr. The program has been shown to play a significant role in launching participants on a path toward productive research careers, which will in turn be impactful on the biomedical research enterprise in Oklahoma.

Does Exercise Prevent Gestational Diabetes Mellitus in Pregnant Women? A Clin-IQ.

Excessive weight gain during pregnancy has been on the rise globally, leading to increased prevalence of gestational diabetes mellitus (GDM). A diagnosis of GDM often leads to pregnancy and infant-related complications. Regular exercise may have the potential to prevent GDM. However, evidence surrounding the utility of exercise during pregnancy as an effective risk reduction intervention has been mixed. This clinical inquiry examined the role of regular exercise during pregnancy in preventing GDM in both obese and normal-weight women and analyzed specific aspects of exercise that make it an effective preventive measure. The review of evidence included 3 meta-analyses, 3 systematic reviews, and 1 umbrella review. Findings identified several components of an exercise program that can reduce GDM risk. Specifically, an exercise intervention of 40- to 60-minute sessions 3 times per week beginning as early as possible during pregnancy and continuing with good adherence over the course of pregnancy yielded clinically significant results. Adhering to a similar exercise routine before pregnancy also was shown to be protective against GDM for all women, but especially so for women who are overweight or obese.

Barriers and strategies to integrate medical genetics and primary care in underserved populations: a scoping review.

Despite clinical and technological advances, serious gaps remain in delivering genetic services due to disparities in workforce distribution and lack of coverage for genetic testing and counseling. Genetic services delivery, particularly in medically underserved populations, may rely heavily on primary care providers (PCPs). This study aims to identify barriers to integrating genetic services and primary care, and strategies to support integration, by conducting a scoping review. Literature synthesis found barriers most frequently cited by PCPs including insufficient knowledge about genetics and risk assessment, lack of access to geneticists, and insufficient time to address these challenges. Telegenetics, patient-centered care, and learning communities are strategies to overcome these barriers. Telegenetics supplements face-to-face clinics by providing remote access to genetic services. It may also be used for physician consultations and education. Patient-centered care allows providers, families, and patients to coordinate services and resources. Access to expert information provides a critical resource for PCPs. Learning communities may represent a mechanism that facilitates information exchange and knowledge sharing among different providers. As PCPs often play a crucial role caring for patients with genetic disorders in underserved areas, barriers to primary care-medical genetics integration must be addressed to improve access. Strategies, such as telegenetics, promotion of evidence-based guidelines, point-of-care risk assessment tools, tailored education in genetics-related topics, and other system-level strategies, will facilitate better genetics and primary care integration, which in turn, may improve genetic service delivery to patients residing in underserved communities.

Cost-Benefit Analysis of Allowing Additional Time in Cleaning Hospital Contact Precautions Rooms.

Increasing cleaning time may reduce hospital-acquired transmission of Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococcus (VRE). We constructed a cost-benefit model to estimate the impact of implementing an enhanced cleaning protocol, allowing hospital housekeepers an additional 15 minutes to terminally clean contact precautions rooms. The enhanced cleaning protocol saved the hospital $758 per terminally-cleaned room when accounting for only C. difficile. Scaling up to a hospital with 100 cases of C. difficile/year, and the US annual C. difficile incidence, cost savings were $75,832/year and $169.8 million/year, respectively. These results may inform infection control strategic decision-making and resource allocation.

Social dynamics of a population-level dashboard for antimicrobial stewardship: A qualitative analysis.

OBJECTIVE: To evaluate antimicrobial stewards' experiences of using a dashboard display integrating local and national antibiotic use data implemented in the U.S. Department of Veterans Affairs (VA). This paper reports early formative evaluation. DESIGN: Qualitative interviewing. SETTING: Eight VA hospitals participated with established antimicrobial stewardship (AS) programs participated in the pilot. PARTICIPANTS: Six infectious disease physicians and eight clinical pharmacists agreed to be interviewed (n = 14). METHODS: A 3-part qualitative interview script was used involving a description of local stewardship activities, a Critical Incident description of dashboard use, and general questions regarding attitudes towards the tool. An inductive open coding approach was used for analysis. RESULTS: We found 4 themes showing the complexities of using stewardship tools: (1) Data validity is socially negotiated; (2) Performance feedback motivates and persuades social goals when situated in an empirical distribution; (3) Shared problem awareness is aided by authoritative data; and (4) The AS dashboard encourages connections with local quality improvement culture. CONCLUSIONS: Social dimensions of AS tool use emerged as distinct from, and equally important as decision support provided by the dashboard. Successful stewardship tools should be designed to support both the social and cognitive needs of users.

Decreases in Antimicrobial Use Associated With Multihospital Implementation of Electronic Antimicrobial Stewardship Tools.

BACKGROUND: Antimicrobial stewards may benefit from comparative data to inform interventions that promote optimal inpatient antimicrobial use. METHODS: Antimicrobial stewards from 8 geographically dispersed Veterans Affairs (VA) inpatient facilities participated in the development of antimicrobial use visualization tools that allowed for comparison to facilities of similar complexity. The visualization tools consisted of an interactive web-based antimicrobial dashboard and, later, a standardized antimicrobial usage report updated at user-selected intervals. Stewards participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antimicrobial agents, anti-methicillin-resistant Staphylococcus aureus [anti-MRSA] agents, and antipseudomonal agents) was analyzed using a pre-post (January 2014-January 2016 vs July 2016-January 2018) design with segmented regression and external comparison with uninvolved control facilities (n = 118). RESULTS: Intervention sites demonstrated a 2.1% decrease (95% confidence interval [CI], -5.7% to 1.6%) in total antimicrobial use pre-post intervention vs a 2.5% increase (95% CI, 0.8% to 4.1%) in nonintervention sites (absolute difference, 4.6%; P = .025). Anti-MRSA antimicrobial use decreased 11.3% (95% CI, -16.0% to -6.3%) at intervention sites vs a 6.6% decrease (95% CI, -9.1% to -3.9%) at nonintervention sites (absolute difference, 4.7%; P = .092). Antipseudomonal antimicrobial use decreased 3.4% (95% CI, -8.2% to 1.7%) at intervention sites vs a 3.6% increase (95% CI, 0.8% to 6.5%) at nonintervention sites (absolute difference, 7.0%; P = .018). CONCLUSIONS: Comparative data visualization tool use by stewards at 8 VA facilities was associated with significant reductions in overall antimicrobial and antipseudomonal use relative to uninvolved facilities.

Impact and Outcomes of the Oklahoma IDeA Network of Biomedical Research Excellence Summer Undergraduate Research Program.

Participating in research under the guidance of faculty mentors can increase undergraduate students' skills, knowledge, and confidence in conducting scientific research and pursing a scientific career. The Oklahoma IDeA Network of Biomedical Research Excellence (OK-INBRE) in the US state of Oklahoma has established an infrastructure to develop future researchers and healthcare professionals by providing students with summer internships. However, long-term benefits have not typically been well quantified, and most prior investigations examining benefits and outcomes of undergraduate summer research experiences have been descriptive and/or observational in nature. To assess OK-INBRE summer program participants, educational and career outcomes were systematically tracked. Data for evaluation included 1) primary sources containing responses to learning surveys from OK-INBRE and national cohorts over a three-year period, and 2) secondary sources from the Oklahoma State Regents for Higher Education (OSRHE), that track educational outcomes of Oklahoma students over a 15-year period. Frequency statistics were compiled and bivariate analyses were conducted to examine participant academic and career outcomes. Survey responses reported higher satisfaction in various dimensions of learning among OK-INBRE students than among corresponding national cohorts, particularly on dimensions of knowledge, skills, and understanding of sciences. The OSRHE data showed that, compared with those in the control group, there was a 100% increase in OK-INBRE participants who enrolled in or had completed a professional degree (e.g., MD/DO) and a 175% increase in students attending a biomedical science graduate program. These findings demonstrate the contribution of the OK-INBRE program in promoting science education and professions.

Is There Less Opioid Abuse in States Where Marijuana Has Been Decriminalized, Either for Medicinal or Recreational Use? A Clin-IQ.

Opioid use, abuse, and associated mortality have reached an epidemic level. In some states, cannabis is being used to treat chronic pain. To examine the hypothesis that medical marijuana legislation may reduce adverse opioid-related outcomes if patients substitute cannabis for opioids for pain management, we conducted a clinical inquiry (Clin-IQ). We searched Ovid MEDLINE, Ovid MEDLINE In-Process, and Embase for studies using the search terms marijuana, cannabis, legal, marijuana smoking, medical marijuana, opioid-related disorders, cannabis use, medical cannabis, legal aspect, and opiate addiction. We included population-based articles published from January 1, 2012, through December 5, 2018, that assessed the relationship between marijuana use and decriminalization and the aforementioned opioid-related outcomes. Ten peer-reviewed studies met the inclusion criteria; 3 cross-sectional studies, 6 ecologic studies (ie, using aggregate data), and 1 retrospective cohort study. Eight studies reported associations between policies decriminalizing marijuana and reduced prescription opioid use, 1 study was inconclusive, and the retrospective cohort study reported an increase in adverse opioid-related outcomes. These results should be interpreted with caution given limitations associated with the studies' design. Results demonstrating association between marijuana decriminalization and opioid-related outcomes are mixed. Longitudinal studies are needed, and further analysis of this policy should continue to be tracked.

Developing a genetic services assessment tool to inform quality improvement efforts in state genetic service delivery.

PURPOSE: The Institute of Medicine recommended the utilization of metrics to improve quality in health care, although they have rarely been used in genetics. This study developed and tested a set of metrics for a quality assessment tool for genetic services METHODS: A systematic review of literature, guidelines, and consensus statements identified candidate measures for a possible assessment tool. An expert panel conducted a modified Delphi technique to rank the metrics. Ratings were computed to generate a score for each metric, creating a set of metrics for consensus discussions, pilot testing, and feasibility testing in eight Midwestern states. RESULTS: The panel reduced 61 candidate metrics to 21 for pilot testing in two states, which further limited and refined the set to 16 metrics. These 16 were categorized into five domains: service capacity, access to care, data systems, performance reporting, and workforce. Further feasibility testing in one Regional Genetics Collaborative identified the tool's usefulness and barriers to implementation. CONCLUSIONS: These quality metrics for both clinical and public health genetics across the lifespan may help medical professionals and policymakers evaluate quality and cost-effectiveness of genetic services on a statewide basis and stimulate outcome-oriented, health services research in medical genetics and genomics.

Specifying an implementation framework for Veterans Affairs antimicrobial stewardship programmes: using a factor analysis approach.

Objectives: Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programmes (ASPs) may optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify organizational factors that may facilitate ASP design, development and implementation. Methods: Among 130 Veterans Affairs facilities that offered acute care, we classified organizational variables supporting antimicrobial stewardship activities into three PARiHS domains: evidence to encompass sources of knowledge; contexts to translate evidence into practice; and facilitation to enhance the implementation process. We conducted a series of exploratory factor analyses to identify conceptually linked factor scales. Cronbach's alphas were calculated. Variables with large uniqueness values were left as single factors. Results: We identified 32 factors, including six constructs derived from factor analyses under the three PARiHS domains. In the evidence domain, four factors described guidelines and clinical pathways. The context domain was broken into three main categories: (i) receptive context (15 factors describing resources, affiliations/networks, formalized policies/practices, decision-making, receptiveness to change); (ii) team functioning (1 factor); and (iii) evaluation/feedback (5 factors). Within facilitation, two factors described facilitator roles and tasks and five captured skills and training. Conclusions: We mapped survey data onto PARiHS domains to identify factors that may be adapted to facilitate ASP uptake. Our model encompasses mostly mutable factors whose relationships with performance outcomes may be explored to optimize antimicrobial use. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance.

Disseminating, implementing, and evaluating patient-centered outcomes to improve cardiovascular care using a stepped-wedge design: healthy hearts for Oklahoma.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the US and incurs high health care costs. While many initiatives promote the implementation of ABCS (aspirin therapy, blood pressure control, cholesterol management, and smoking cessation) measures, most primary care practices (PCPs) lack quality improvement (QI) support and resources to achieve meaningful targets. The Healthy Hearts for Oklahoma (H2O) Study proposes to build a QI infrastructure by (1) constructing a sustainable Oklahoma Primary Healthcare Improvement Collaborative (OPHIC) to support dissemination and implementation (D&I) of QI methods; (2) providing QI support in PCPs to better manage patients at risk for CVD events. Parallel to infrastructure building, H2O aims to conduct a comprehensive evaluation of the QI support D&I in primary care and assess the relationship between QI support uptake and changes in ABCS measures. METHODS: H2O has partnered with public health agencies and communities to build OPHIC and facilitate QI. H2O has 263 small primary care practices across Oklahoma that receive the bundled QI intervention to improve ABCS performance. A stepped-wedge designed is used to evaluate D&I of QI support. Changes in ABCS measures will be estimated as a function of various components of the QI support and capacity and readiness of PCPs to change. Notes from academic detailing and practice facilitation sessions will be analyzed to help interpret findings on ABCS performance. DISCUSSION: H2O program is designed to improve cardiovascular health and outcomes for more than 1.25 million Oklahomans. The infrastructure established as a result of this funding will help reach medically underserved Oklahomans, particularly among rural and tribal populations. Lessons learned from this project will guide future strategies for D&I of evidence-based practices in PCPs. Trained practice facilitators will continue to serve as critical resource to assists small, rural PCPs in adapting to the ever-changing health environment and continue to deliver quality care to their communities.

The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma.

PURPOSE: In primary care practices, sustainability of performance improvements and ability to deliver continuity of care to patients can be adversely affected by major disruptive events, such as relocations and changes in ownership, clinicians, and key staff. This study documented the rates of major disruptive events in a cohort of primary care practices in Oklahoma. METHODS: Practices were included if they had existed for 1 year before enrollment and remained in the project for at least 1 year after enrollment. Practice characteristics for 208 practices and major disruptive events during the preenrollment year were collected by survey. Postenrollment major disruptive events were prospectively collected by practice facilitators. We compiled frequency statistics and conducted bivariate analyses for each data set. RESULTS: Of 208 eligible practices, 81 (39%) were clinician owned, and 51 (25%) were health system owned. One hundred nine practices (52%) were in nonmetropolitan counties. One hundred seventy-five major disruptive events occurred in 120 (58%) practices during the preenrollment year, with 42 practices having experienced multiple events. During the first year of the project, 89 major disruptive events occurred in 67 (32%) practices, with 20 practices experiencing multiple events. The major disruptive events reported most often during both periods were loss of personnel and implementation of electronic health records and billing systems. Practice size was associated with occurrence of these events. CONCLUSIONS: During a 2-year period, major disruptive events occurred at an alarming rate, adversely affecting quality improvement efforts. Most reported events involved losses of clinicians and staff. More research is needed to identify and address the root causes of these events.

Association of Inpatient Antimicrobial Utilization Measures with Antimicrobial Stewardship Activities and Facility Characteristics of Veterans Affairs Medical Centers.

BACKGROUND: Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable. Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable. OBJECTIVE: To determine associations between ASPs and facility characteristics, and inpatient antimicrobial utilization measures in the Veterans Affairs (VA) system in 2012. DESIGN: In 2012, VA administered a survey on antimicrobial stewardship practices to designated ASP contacts at VA acute care hospitals. From the survey, we identified 34 variables across 3 domains (evidence, organizational context, and facilitation) that were assessed using multivariable least absolute shrinkage and selection operator regression against 4 antimicrobial utilization measures from 2012: aggregate acute care antimicrobial use, antimicrobial use in patients with non-infectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral antimicrobial therapy, and double anaerobic coverage. SETTING: All 130 VA facilities with acute care services. RESULTS: Variables associated with at least 3 favorable changes in antimicrobial utilization included presence of postgraduate physician/pharmacy training programs, number of antimicrobial-specific order sets, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases (ID) attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist. Variables associated with 2 unfavorable measures included bed size, the level of engagement with VA Antimicrobial Stewardship Task Force online resources, and utilization of antimicrobial stop orders. CONCLUSIONS: Formalization of ASP processes and presence of pharmacy and ID expertise are associated with favorable utilization. Systematic de-escalation review and order set establishment may be high-yield interventions. Journal of Hospital Medicine 2017;12:301-309.

Impact of a National Cancer Prevention and Treatment Program on the Prevalence of Late-Stage Breast Cancer Diagnoses in Oklahoma.

In 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) to provide coverage through Medicaid to women who screened positive for breast and cervical cancer. We aimed to determine if late-stage breast cancer prevalence decreased among Oklahoma women after passage of BCCPTA. Data were obtained from the Oklahoma Central Cancer Registry during 2000-2011. We estimated prevalence proportion ratios (PPR) using modified Poisson regression between the proportion of women with late-stage breast cancer and timing of diagnosis related to BCCPTA. Among uninsured women, the probability of being diagnosed with late-stage cancer after enactment of the BCCPTA was 0.80 (95% CI: 0.67, 0.96) times the probability before enactment. This was significant among uninsured women living in metro counties (PPR: 0.74, 95% CI: 0.61, 0.90) but not in non-metro counties (PPR: 1.05, 95% CI: 0.71, 1.56). These findings may be similar to other rural states with large uninsured populations.

Characteristics of Antimicrobial Stewardship Programs at Veterans Affairs Hospitals: Results of a Nationwide Survey.

BACKGROUND Antimicrobial stewardship programs (ASPs) are variably implemented. OBJECTIVE To characterize variations of antimicrobial stewardship structure and practices across all inpatient Veterans Affairs facilities in 2012 and correlate key characteristics with antimicrobial usage. DESIGN A web-based survey regarding stewardship activities was administered to each facility's designated contact. Bivariate associations between facility characteristics and inpatient antimicrobial use during 2012 were determined. SETTING Total of 130 Veterans Affairs facilities with inpatient services. RESULTS Of 130 responding facilities, 29 (22%) had a formal policy establishing an ASP, and 12 (9%) had an approved ASP business plan. Antimicrobial stewardship teams were present in 49 facilities (38%); 34 teams included a clinical pharmacist with formal infectious diseases (ID) training. Stewardship activities varied across facilities, including development of yearly antibiograms (122 [94%]), formulary restrictions (120 [92%]), stop orders for antimicrobial duration (98 [75%]), and written clinical pathways for specific conditions (96 [74%]). Decreased antimicrobial usage was associated with having at least 1 full-time ID physician (P=.03), an ID fellowship program (P=.003), and a clinical pharmacist with formal ID training (P=.006) as well as frequency of systematic patient-level reviews of antimicrobial use (P=.01) and having a policy to address antimicrobial use in the context of Clostridium difficile infection (P=.01). Stop orders for antimicrobial duration were associated with increased use (P=.03). CONCLUSIONS ASP-related activities varied considerably. Decreased antibiotic use appeared related to ID presence and certain select practices. Further statistical assessments may help optimize antimicrobial practices. Infect Control Hosp Epidemiol 2016;37:647-654.

Organizational Factors Affecting the Likelihood of Cancer Screening Among VA Patients.

BACKGROUND: Preventive service delivery, including cancer screenings, continues to pose a challenge to quality improvement efforts. Although many studies have focused on person-level characteristics associated with screening, less is known about organizational influences on cancer screening. OBJECTIVES: This study aims to understand the association between organizational factors and adherence to cancer screenings. METHODS: This study employed a cross-sectional design using organizational-level, patient-level, and area-level data. Dependent variables included breast, cervical, and colorectal cancer screening. Organizational factors describing resource sufficiency were constructed using factor analyses from a survey of 250 Veterans Affairs primary care directors. We conducted random-effects logistic regression analyses, modeling cancer screening as a function of organizational factors, controlling for patient-level and area-level factors. RESULTS: Overall, 87% of the patients received mammograms, 92% received cervical and 78% had colorectal screening. Quality improvement orientation increased the odds of cervical [odds ratio (OR): 1.27; 95% confidence interval (CI), 1.03-1.57] and colorectal cancer screening (OR: 1.10; 95% CI, 1.00-1.20). Authority in determining primary care components increased the odds of mammography screening (OR: 1.23; 95% CI, 1.03-1.51). Sufficiency in clinical staffing increased the odds of mammography and cervical cancer screenings. Several patient-level factors, serving as control variables, were associated with achievement of screenings. CONCLUSIONS: Resource sufficiency led to increased odds of screening possibly because they promote excellence in patient care by conveying organizational goals and facilitate goal achievement with resources. Complementary to patient-level factors, our findings identified organizational processes associated with better performance, which offer concrete strategies in which facilities can evaluate their capabilities to implement best practices to foster and sustain a culture of quality care.

The interplay of contextual elements in implementation: an ethnographic case study.

BACKGROUND: Contextual elements have significant impact on uptake of health care innovations. While existing conceptual frameworks in implementation science suggest contextual elements interact with each other, little research has described how this might look in practice. To bridge this gap, this study identifies the interconnected patterns among contextual elements that influence uptake of an anticoagulation clinic improvement initiative. METHODS: We completed 51 semi-structured interviews and ethnographic observations across five case study sites involved in an evidence-based practice (EBP) quality improvement initiative. We analyzed data in NVivo 10 using an a priori approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and an emergent thematic analysis. RESULTS: Key contextual elements, such as leadership, teamwork, and communication, interacted with each other in contributing to site-level uptake of the EBP, often yielding results that could not be predicted by looking at just one of these elements alone. Sites with context conducive to change in these areas predictably had high uptake, while sites with uniformly weak contextual elements had low uptake. Most sites presented a mixed picture, with contextual elements being strongly supportive of change in some areas and weak or moderate in others. In some cases, we found that sites with strong context in at least one area only needed to have adequate context in other areas to yield high uptake. At other sites, weak context in just one area had the potential to contribute to low uptake, despite countervailing strengths. Even a site with positive views of EBPs could not succeed when context was weak. CONCLUSION: Interrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others. Accounting for interconnections among elements enables PARIHS to more fully describe the determinants of successful implementation as they operate in real-world settings.