Association of organizational culture and climate with variation in the clinical outcomes of collaborative care for maternal depression in community health centers.

Background: Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers. Method: Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9). Results: After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate. Conclusions: Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.

While many implementation theories espouse the importance of organizational culture and climate for the successful implementation of evidence-based practices in primary care, there is little research that tests this hypothesis. Since there are interventions which can improve organizational culture and climate, having more evidence that these factors are associated with implementation would support efforts to modify these aspects of a community health center as a means of improving implementation. This study showed that the extent to which patients clinically benefitted from the evidence-based Collaborative Care Model for maternal depression was related to the prevailing culture and climate of community health centers where they received treatment. Specifically, women seen at centers in which the staff and providers indicated that their organizations prioritize responsiveness to patients' needs over competing organizational goals and maintain competence in up-to-date treatment models (referred to as proficient culture), and understand their role in the organization and receive the cooperation and support they need from colleagues and supervisors to perform their job well (functional climate) were associated with sustained improvements in depression symptoms. This benefit was independent of other factors already known to be associated with these outcomes. Implementation strategies that target organizational culture (i.e., priorities and expectations for staff) and climate (i.e., quality of working environment) may improve the clinical outcomes of integrated collaborative care models for depression and reduce the commonly seen variation in outcomes across health centers.

Intravascular ultrasound analysis of intraplaque versus subintimal tracking in percutaneous intervention for coronary chronic total occlusions: One year outcomes.

OBJECTIVES: We sought to determine the 1-year outcomes of patients receiving successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures comparing subintimal versus intraplaque wire tracking patterns. BACKGROUND: CTO PCI utilizes both intraluminal and subintimal wire tracking to achieve successful percutaneous revascularization. Intravascular ultrasound (IVUS) can be used to precisely determine the path of wire tracking. METHODS: From 2014 to 2016, data from patients undergoing CTO PCI were collected in a single-center database. The primary composite endpoint was target vessel failure (TVF) defined as cardiovascular death, target vessel myocardial infarction (MI), or target vessel revascularization (TVR). RESULTS: In total 157 patients with successful CTO PCI and concomitant IVUS imaging completed 1-year follow-up. Subintimal tracking was detected in 53.5% of cases and those patients had a higher incidence of prior PCI, prior coronary artery bypass grafting, and higher J-CTO score. At 1-year, the unadjusted rate of TVF in the subintimal tracking group was higher than the intraplaque group (17.9 vs. 6.9%, HR 2.74, 95% CI 1.00-7.54, P = 0.04), driven by numerically higher rates of TVR and peri-procedural MI. After multivariable adjustment, no significant differences in the rates of the TVF between subintimal vs. intraplaque groups were present at 1-year (TVF: HR 1.51, 95% CI 0.38-6.00, P = 0.55). Landmark analysis excluding in-hospital events showed no significant differences in TVF to 1-year. CONCLUSIONS: IVUS-detected subintimal tracking was observed in over half of successful CTO PCI cases and correlated with baseline and angiographic factors that contributed to the overall rate of TVF at 1-year.

Comparison of Percutaneous and Surgical Right Ventricular Assist Device Support After Durable Left Ventricular Assist Device Insertion.

BACKGROUND: Early right ventricular (RV) failure after left ventricular assist device (LVAD) implantation increases morbidity and mortality. Percutaneous right ventricular assist device (pRVAD) support is an alternative to more invasive surgical RVAD (sRVAD). METHODS AND RESULTS: We retrospectively reviewed patients receiving isolated pRVAD or sRVAD after durable LVAD at our center in the years 2007-2018. Hemodynamic parameters before and after implantation and survival outcomes were compared among groups. Nineteen patients received pRVAD and 21 sRVAD. Hemodynamic parameters improved immediately with the use of pRVAD; central venous pressure decreased (from 15.9 ± 2.4 to 12.3 ± 3.2 mm Hg; P<.001) and cardiac index increased (from 2.4 ± 0.5 to 3.5 ± 0.8 L·min-1·m-2; P<.001). These were sustained after device removal and were similar to those with the use of sRVAD. Patients with pRVAD required fewer blood transfusions and mechanically ventilated days than those with sRVAD. Among survivors, intensive care unit and hospital days were fewer with the use of pRVAD: 21 (16-27) versus 34 (27-46) ICU days (P = .01); 43.5 (30-66) versus 91 (62-111) hospital days (P = .03). There was no significant difference in 30-day mortality with the use of pRVAD compared with sRVAD (21.1% vs 42.9%; P = .14), but there was a trend toward a higher rate of discharge free from hemodialysis (73.7% vs 47.6%; P = .09). CONCLUSIONS: Novel pRVAD systems for RV failure provide hemodynamic benefits similar to sRVAD, are associated with less morbidity, and should be considered as an alternative to sRVAD.

The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study.

UNLABELLED: ABSTBACKGROUND: Evidence-based practices have not been routinely adopted in community mental health organizations despite the support of scientific evidence and in some cases even legislative or regulatory action. We examined the association of clinician attitudes toward evidence-based practice with organizational culture, climate, and other characteristics in a nationally representative sample of mental health organizations in the United States. METHODS: In-person, group-administered surveys were conducted with a sample of 1,112 mental health service providers in a nationwide sample of 100 mental health service institutions in 26 states in the United States. The study examines these associations with a two-level Hierarchical Linear Modeling (HLM) analysis of responses to the Evidence-Based Practice Attitude Scale (EBPAS) at the individual clinician level as a function of the Organizational Social Context (OSC) measure at the organizational level, controlling for other organization and clinician characteristics. RESULTS: We found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice. CONCLUSIONS: The findings suggest that organizational intervention strategies for improving the organizational social context of mental health services may contribute to the success of evidence-based practice dissemination and implementation efforts by influencing clinician attitudes.

Preparation and properties of a novel class of polyhydroxyalkanoate copolymers.

Polyhydroxyalkanoates (PHAs) are biodegradable aliphatic polyesters, known to be produced by many common microorganisms. Nodax is a recently introduced family of PHA copolymers comprising 3-hydroxybutyrate units and a relatively small amount of other medium chain length 3-hydroxyalkanoate (mcl-3HA) comonomers with side groups of at least three carbon units or more. There are several different grades of copolymers available, depending on the average molecular weight, average mcl-3HA content within the copolymer, and side group chain length of the chosen mcl-3HA unit. PHA copolymers with different mcl-3HA types and contents can be made either by bacterial fermentation or by chemical synthesis. The incorporation of mcl-3HA units into PHAs effectively lowers the crystallinity and T(m) in a manner similar to the effect of alpha-olefins in linear low-density polyethylene. The T(m) can be lowered well below the thermal decomposition temperature of PHAs to make this material much easier to process. The reduced crystallinity provides the ductility and toughness required for many practical applications. The mcl-3HA content regulates the T(m) and crystallinity of copolymer almost independently of the branch size, as long as more than three carbons are present in the side group. On the other hand, the side group chain length of the mcl-3HA has a profound effect on the flexibility of copolymer.

Formation of short chain length/medium chain length polyhydroxyalkanoate copolymers by fatty acid beta-oxidation inhibited Ralstonia eutropha.

Ralstonia eutropha has been considered as a bacterium, incorporating hydroxyalkanoates of less than six carbons only into polyhydroxyalkanoates (PHAs). Cells of the wild type cultivated with sodium octanoate as the carbon source in the presence of the fatty acid beta-oxidation inhibitor sodium acrylate synthesized PHAs composed of the medium chain length hydroxyalkanoates (3HA(MCL)) 3-hydroxyhexanoate (3HHx) and 3-hydroxyoctanoate (3HO) as well as of 3-hydroxybutyrate and 3-hydroxyproprionate as revealed by gas chromatography, (1)H NMR spectroscopy, and mass spectroscopy. The characterization of the polymer as a tetrapolymer was confirmed by differential solvent extraction and measurement of melting and glass transition temperature depression in the purified polymer compared to PHB. These data suggested that the R. eutropha PHA synthase is capable of incorporating longer chain substrates than suggested by previous in vitro studies. Furthermore, expression of the class II PHA synthase gene phaC1 from P. aeruginosa in R. eutropha resulted in the accumulation of PHAs consisting of 3HA(MCL) contributing about 3-5% to cellular dry weight. These PHAs were composed of nearly equal molar fractions of 3HO and 3-hydroxydecanoate (3HD) with traces of 3HHx. These data indicated that 3HA(MCL)-CoA thioesters were diverted from the fatty acid beta-oxidation pathway towards PHA biosynthesis in recombinant R. eutropha.