Implementation strategies to improve posttraumatic stress disorder care in rural veterans.

PURPOSE: Prior research has noted treatment inequalities in the care of rural veterans with posttraumatic stress disorder (PTSD). This project sought to increase the delivery, or reach, of recommended PTSD treatments in 2 rural health care systems of the Department of Veterans Affairs (VA) using implementation facilitation. METHODS: The quality improvement project involved 6 months of facilitation to 2 low-reach PTSD clinics within 2 VA health care systems. The clinics were matched to a control clinic at another regional system similar in reach, rurality, and patient volume. We compared the delivery of evidence-based psychotherapies (EBPs) for PTSD at 3 timepoints: baseline, 6 months, and 1 year using difference-in-difference effect estimation. Facilitators and barriers of EBP reach were identified through interviews with clinic staff and informed specific implementation plans. We also measured reductions in benzodiazepine prescriptions and polypharmacy to determine the impact of an academic detailing intervention aimed at improving PTSD prescribing practices at the 2 sites. FINDINGS: EBP reach at 6 months more than doubled in the 2 PTSD clinics that received facilitation, while our control clinic experienced a decrease in EBP reach (DID = 24.6; SE = 6.71%). Both intervention clinics identified similar administrative barriers to the delivery of EBPs, offering useful information for improvement at other rural clinics. The use of academic detailing as part of our facilitation intervention further appears to have positively impacted care. CONCLUSIONS: In this preliminary work, facilitation is a promising strategy for increasing the delivery of PTSD EBPs to veterans seen in under-resourced rural VA clinics.

Engaging a community in developing an entertainment-education Spanish-language radio novella aimed at reducing chronic disease risk factors, Alabama, 2010-2011.

BACKGROUND: US Hispanics have disproportionate rates of diabetes and other chronic diseases. We used the entertainment-education approach to develop a Spanish-language radio novella aimed at reducing risk factors for diabetes, obesity, and tobacco use. The approach is based on social cognitive theory and proposes modeling as a source of vicarious learning of outcome and efficacy expectations. COMMUNITY CONTEXT: The Hispanic population in Alabama increased by 145% between 2000 and 2010. Nearly one-quarter of Hispanics aged 18 to 64 live below the federal poverty level, and 49% are uninsured. Several lifestyle factors lead to poor health behaviors in this community. Radio is a popular medium among Hispanic immigrants. The single local Spanish-language radio station reaches a large proportion of the local community and several communities beyond. METHODS: Through various methods, including workshops, review sessions, and other feedback mechanisms, we engaged stakeholders and community members in developing and evaluating a 48-episode radio novella to be broadcast as part of a variety show. We tracked participation of community members in all phases. OUTCOME: Community members participated significantly in developing, broadcasting, and evaluating the intervention. The desired outcome - development of a culturally relevant storyline that addresses salient health issues and resonates with the community - was realized. INTERPRETATION: Our approach to community engagement can serve as a model for other organizations wishing to use community-based participatory methods in addressing Hispanic health issues. The radio novella was a unique approach for addressing health disparities among our community's Hispanic population.

Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department.

We conducted a prospective comparison of blood culture contamination rates associated with dedicated phlebotomists and nonphlebotomy staff in the emergency department (ED) at Parkland Memorial Hospital in Dallas, TX. In addition, hospital charges and lengths of stay were determined for patients with negative, false-positive, and true-positive blood culture results. A total of 5,432 blood culture collections from two ED areas, the western wing of the ED (ED west) and the nonwestern wing of the ED (ED nonwest), were evaluated over a 13-month period. Phlebotomists drew 2,012 (55%) of the blood cultures in ED west while nonphlebotomy staff drew 1,650 (45%) in ED west and 1,770 (100%) in ED nonwest. The contamination rates of blood cultures collected by phlebotomists were significantly lower than those collected by nonphlebotomists in ED west (62/2,012 [3.1%] versus 122/1,650 [7.4%]; P < 0.001). Similar results were observed when rates between phlebotomists in ED west and nonphlebotomy staff in ED nonwest were compared (62/2,012 [3.1%] versus 100/1,770 [5.6%]; P < 0.001). Comparison of median patient charges between negative and false-positive episodes ($18,752 versus $27,472) showed $8,720 in additional charges per contamination event while the median length of stay increased marginally from 4 to 5 days. By utilizing phlebotomists to collect blood cultures in the ED, contamination rates were lowered to recommended levels, with projected reductions in patient charges of approximately $4.1 million per year.

Is bigger better? Driving factors of POTW performance in New York.

Like many regions around the world, New York State, USA, faces challenges in meeting wastewater treatment quality standards because of aging infrastructure, limited funding, shifting demographics and increasingly stringent environmental regulations. In recent decades construction of new wastewater treatment and distribution infrastructure in NY has most often occurred in exurban communities and suburban developments that are less dense than traditional urban cores. Here, we examine the role of size and capacity utilization on wastewater treatment effectiveness with respect to critical effluent parameters, and additionally explore which common facility engineering controls influence water quality treatment using a unique dataset of descriptive information. Our results challenge conventional wisdom, suggesting that the largest facilities (>30,000 m3/d), not the smallest (<300 m3/d), discharge TSS, BOD, and coliform at significantly higher relative effluent concentrations (i.e., the ratio of discharged concentrations to allowable limits). Capacity utilization was also positively correlated to higher concentrations of TSS, BOD, and coliform effluent concentrations in larger facilities, though those concentrations were often within regulated limits. This implies that smaller-sized facilities may perform better in terms of environmental quality, but that the largest facilities demonstrate efficiency in the sense that they are not "over-treating" wastewater while avoiding violations. Results from NY suggest that medium sized facilities (300-30,000 m3/d) are sophisticated enough to incorporate appropriate unit processes, and employ operators with sufficient training and oversight, to reach treatment outcomes that are both reliable and of high quality.