Implementation of video telehealth to improve access to evidence-based psychotherapy for posttraumatic stress disorder.

BACKGROUND: Increasing access to psychotherapy for posttraumatic stress disorder (PTSD) is a primary focus of the Department of Veterans Affairs (VA) healthcare system. Delivery of treatment via video telehealth can expand availability of treatment and be equally effective as in-person treatment. Despite VA efforts, barriers to establishing telehealth services remain, including both provider acceptance and organizational obstacles. Thus, development of specific strategies is needed to implement video telehealth services in complex healthcare systems, like the VA. MATERIALS AND METHODS: This project was guided by the Promoting Action on Research Implementation in Health Services framework and used external facilitation to increase access to psychotherapy via video telehealth. The project was conducted at five VA Medical Centers and their associated community clinics across six states in the South Central United States. RESULTS: Over a 21-month period, 27 video telehealth clinics were established to provide greater access to evidence-based psychotherapies for PTSD. Examination of change scores showed that participating sites averaged a 3.2-fold increase in unique patients and a 6.5-fold increase in psychotherapy sessions via video telehealth for PTSD. Differences between participating and nonparticipating sites in both unique patients and encounters were significant (p=0.041 and p=0.009, respectively). Two groups emerged, separated by degree of engagement in the facilitation intervention. Facilitation was perceived as useful by providers. CONCLUSIONS: To our knowledge, this is the first prospective study of external facilitation as an implementation strategy for telehealth. Our findings suggest that external facilitation is an effective and acceptable strategy to support providers as they establish clinics and make complex practice changes, such as implementing video telehealth to deliver psychotherapy.

Screening analysis of human pharmaceutical compounds in U.S. surface waters.

The PhATE (Pharmaceutical Assessment and Transport Evaluation) model presented in this paper was developed as a tool to estimate concentrations of active pharmaceutical ingredients (APIs) in U.S. surface waters that result from patient use (or consumption) of medicines. PhATE uses a mass balance approach to model predicted environmental concentrations (PECs) in 11 watersheds selected to be representative of most hydrologic regions of the United States. The model divides rivers into discrete segments. It estimates the mass of API that enters a segment from upstream or from publicly owned treatment works (POTW) and is subsequently lost from the segment via in-stream loss mechanisms or flow diversions (i.e., man-made withdrawals). POTW discharge loads are estimated based on the population served, the API use per capita, the potential loss of the compound associated with human use (e.g., metabolism), and the portion of the API mass removed in the POTW. Simulations using three surrogate compounds showthat PECs generated by PhATE are generally within an order of magnitude of measured concentrations and that the cumulative probability distribution of PECs for all watersheds included in PhATE is consistent with the nationwide distribution of measured concentrations of the surrogate compounds. Model simulations for 11 APIs yielded four categories of results. (1) PECs fit measured data for two compounds. (2) PECs are below analytical method detection limits and thus are consistent with measured data for three compounds. (3) PECs are higher than (i.e., not consistent with) measured data for three compounds. However, this may be the consequence of as yet unidentified depletion mechanisms. (4) PECs are several orders of magnitude below some measured data but consistentwith most measured data forthree compounds. For the fourth category, closer examination of sampling locations suggests that the field-measured concentrations for these compounds do not accurately reflect human use. Overall, these results demonstrate that PhATE may be used to predict screening-level concentrations of APIs and related compounds in the environment as well as to evaluate the suitability of existing fate information for an API.