Implementation processes are often long and complex, requiring sustained facilitation efforts. Drawing on organizational and implementation literature, we examined the influence of senior management ...support (SMS), middle management support (MMS), facilitator team time availability (TIME) and team continuity (CONTINUITY) on sustainment of internal facilitation activities. For 2 years, we followed 10 small rural hospitals implementing TeamSTEPPS, a patient safety program, and conducted quarterly interviews with key informants. We coded, calibrated, and analyzed the data using the fuzzy-set qualitative comparative analysis. We found that five hospitals sustained facilitation activities and the combination of SMS, MMS, and CONTINUITY (i.e., presence of all three factors) was a sufficient condition for sustainment. Five other hospitals did not sustain facilitation activities and they either lacked MMS or lacked both TIME and CONTINUITY. In follow-up analyses, we found that team leadership continuity also influenced sustainment patterns. We discussed the implications for research and practice.
Implementation models, frameworks, and theories recognize the importance of activities that facilitate implementation success. However, little is known about internal facilitation activities that ...hospital personnel engage in during implementation efforts.
The aim of the study was to examine internal facilitation activities at 10 critical access hospitals in rural Iowa during their implementation of TeamSTEPPS, a patient safety intervention, and to identify characteristics that distinguish different types of facilitation activities.
We followed 10 critical access hospitals for 2 years after the onset of implementation, conducting quarterly interviews with key informants. On the basis of the transcripts from the first two quarters, a coding template was developed using inductive analyses. The template was then applied deductively to code all interview transcripts. Using comparative analysis, we examined the characteristics that distinguish between the facilitation types.
We identified four types of facilitation activities-Leadership, Buy-in, Customization, and Accountability. Individuals and teams engaged in different types of facilitation activities, both in a planned and an ad hoc manner. These activities targeted at both people and practices and exhibited varying temporal patterns (start and peak time).
There are four types of facilitation activities that hospitals engage in while implementing evidence-based practices, offering a parsimonious way to characterize facilitation activities. New theoretical and empirical research opportunities are discussed.
Understanding the types of facilitation activities and their distinguishing characteristics can assist managers in planning and executing implementations of evidence-based interventions.
This study investigates outcomes from two federal grant programs: the Evidence-Based Tele-Behavioral Health Network Program (EB THNP) funded from September 2018 to August 2021 and the Substance Abuse ...Treatment Telehealth Network Grant Program (SAT TNGP) funded from September 2017 to August 2020. As part of the health services implementation program, the aims of this study were to evaluate outcomes in patient symptoms of depression and anxiety across the programs' 17 grantees and 95 associated sites, with each grantee having data from telehealth patients and from an in-person comparison group.
The research design is a prospective multi-site observational study. Each grantee provided data on a nonrandomized convenience sample of telehealth patients and an in-person comparison group from sites with similar rural characteristics and during the same time period. Patient characteristics were collected at treatment initiation, and clinical outcome measures were collected at baseline and monthly. The validated clinical outcome measure instruments included the Patient Health Questionnaire-9 (PHQ-9) for depression symptoms and the Generalized Anxiety Disorder-7 (GAD-7) scale for anxiety-related symptoms. Linear mixed models, with grantee as the random effect, were used to determine the association of behavioral health delivery (telehealth versus in-person) on the one-month change in PHQ-9 and GAD-7 while adjusting for covariates.
Across a total of 1,514 patients, one-month change scores were improved indicating that PHQ-9 and GAD-7 scores decreased from baseline to the one-month follow-up at similar rates in both the in-person and telehealth groups. Reduction in scores averaged 2.8 for the telehealth treatment group and 2.9 for the in-person treatment group in the PHQ-9 subsample and 2.0 for the telehealth treatment group and 2.4 for the in-person treatment group in the GAD-7 subsample. There was no statistically significant association between the modality of care (telehealth treatment group versus in-person comparison group) and the one-month change scores for either PHQ-9 or GAD-7. Individuals with higher baseline scores demonstrated the greatest decrease in scores for both measures. Upon adjusting for baseline scores and grantee program, patient demographics were not found to be significantly associated with change in anxiety or depression symptoms.
In our very large pragmatic study comparing behavioral health treatment delivered to a population of patients in rural, underserved communities, we found no clinical or statistical differences in improvements in depression or anxiety symptoms as measured by the PHQ-9 and GAD-7 between patients treated via telehealth or in-person.
To identify factors associated with rural sepsis patients' bypassing rural emergency departments to seek emergency care in larger hospitals, and to measure the association between rural hospital ...bypass and sepsis survival.
Observational cohort study.
Emergency departments of a rural Midwestern state.
All adults treated with severe sepsis or septic shock between 2005 and 2014, using administrative claims data.
Patients bypassing local rural hospitals to seek care in larger hospitals.
A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their emergency department care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs 72.7 yr; p < 0.001) and were more likely to have commercial insurance (19.6% vs 10.6%; p < 0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%; p < 0.001), metastatic cancer (5.9% vs 3.2%; p < 0.001), and diabetes with complications (25.2% vs 21.6%; p = 0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95% CI, 2.2-8.9%) in mortality.
Most rural patients with sepsis seek care in local emergency departments, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality.
Tele-emergency services provide immediate and synchronous audio/video connections, most commonly between rural low-volume hospitals and an urban "hub" emergency department. We performed a systematic ...literature review to identify tele-emergency models and outcomes. We then studied a large tele-emergency service in the upper Midwest. We sent a user survey to all seventy-one hospitals that used the service and received 292 replies. We also conducted telephone interviews and site visits with ninety clinicians and administrators at twenty-nine of these hospitals. Participants reported that tele-emergency improves clinical quality, expands the care team, increases resources during critical events, shortens time to care, improves care coordination, promotes patient-centered care, improves the recruitment of family physicians, and stabilizes the rural hospital patient base. However, inconsistent reimbursement policy, cross-state licensing barriers, and other regulations hinder tele-emergency implementation. New value-based payment systems have the potential to reduce these barriers and accelerate tele-emergency expansion.
Telehealth studies have highlighted the positive benefits of having the service in rural areas. However, there is evidence of limited adoption and utilization. Our objective was to evaluate this gap ...by exploring U.S. healthcare systems' experience in implementing telehealth services in rural hospital emergency departments (TeleED) and by analyzing factors influencing its implementation and sustainability.
We conducted semi-structured interviews with 18 key informants from six U.S. healthcare systems (hub sites) that provided TeleED services to 65 rural emergency departments (spoke sites). All used synchronous high-definition video to provide the service. We applied an inductive qualitative analysis approach to identify relevant quotes and themes related to TeleED service uptake facilitators and barriers.
We identified three stages of implementation: 1) the start-up stage; 2) the utilization stage; and 3) the sustainment stage. At each stage, we identified emerging factors that can facilitate or impede the process. We categorized these factors into eight domains: 1) strategies; 2) capability; 3) relationships; 4) financials; 5) protocols; 6) environment; 7) service characteristics; and 8) accountability.
The implementation of healthcare innovation can be influenced by multiple factors. Our study contributes to the field by highlighting key factors and domains that play roles in specific stages of telehealth operation in rural hospitals. By appreciating and responding to these domains, healthcare systems may achieve more predictable and favorable implementation outcomes. Moreover, we recommend strategies to motivate the diffusion of promising innovations such as telehealth.
Background
The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of ...cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes.
Objective
To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM.
Design
Comparative effectiveness matched cohort study.
Patients
Veterans aged 65 years and older treated for CHF, COPD, or DM.
Main Measures
We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality.
Key Results
A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio aOR 1.01, 95% confidence interval 95%CI 0.98–1.05) or DM (aOR 1.00, 95%CI 0.97–1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09–1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05–1.13), COPD (1.24, 95%CI 1.18–1.31), and DM (aOR 1.03, 95%CI 1.00–1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67–0.73) and DM (aOR 0.79, 95%CI 0.75–0.83), but higher in COPD (aOR 1.08, 95%CI 1.00–1.16).
Conclusions
The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.
Soluble small molecule organic semiconductors combine the high-performance of small molecule organic semiconductors with the versatile processability of polymeric materials, but the control of device ...performance and uniformity is challenged by the complex film microstructure formed in these materials, and its strong dependence on processing conditions. These films crystallize via a nucleation and growth mechanism that can be difficult to control. In this study we used highly fluorinated self-assembled monolayers (SAMs) to modify the surface of the source and drain contacts and improve the performance of organic thin-film transistors (OTFTs) through controlling film microstructure and lowering the contact resistance. We reached charge carrier mobilities as high as 5.7 cm2/V in 2,8-Difluoro-5,11-bis(triethylsilylethynyl) anthradithiophene (diF-TES ADT), one order of magnitude greater than what we obtained in devices on untreated substrates, and on par with the value reported for single crystal devices. Kelvin probe measurements distinguished an increase in the work function between 0.28 eV and 0.5 eV, depending on the molecular structure of the SAM. Selected area electron diffraction (SAED) confirmed the preferential “edge-on” molecular orientation of the semiconductor. We discuss the device performance in relation to the film morphology and contact resistance.
Display omitted
•We controlled film crystallization in solution deposited organic semiconductors with the use of highly fluorinated SAM treatment.•SAM treatment minimizes the contribution of the inter-spherulite boundaries and lowers the contact resistance.•We obtained OTFT performance on par with single crystal devices by controlling film crystallization and improving injection.
ObjectiveThe purpose of this study was to evaluate the impact of telemedicine in clinical management and patient outcomes of patients presenting to rural critical access hospital emergency ...departments (EDs) with suicidal ideation or attempt.MethodsRetrospective propensity-matched cohort study of patients treated for suicidal attempt and ideation in 13 rural critical access hospital EDs participating in a telemedicine network. Patients for whom telemedicine was used were matched 1:1 to those who did not have telemedicine as an exposure (n=139 TM+, n=139 TM–) using optimal matching of propensity scores based on administrative data. Our primary outcome was ED length-of-stay (LOS), and secondary outcomes included admission proportion, use of chemical or physical restraint, 30 day ED return, involuntary detention orders, treatment/follow-up plan and 6-month mortality. Analyses for multivariable models were conducted using conditional linear and logistic regression clustered on matched pairs with purposeful selection of covariates.ResultsMean ED LOS was not associated with telemedicine consultation among all patients, but was associated with a 29.3% decrease in transferred patients (95% CI 11.1 to 47.5). The adjusted odds of hospital admission (either local or through transfer) was 2.35 (95% CI 1.10 to 5.00) times greater among TM+ patients compared with TM– patients. Involuntary hold placement was lower in those exposed to telemedicine (adjusted odds ratio (aOR): 0.48; 95% CI 0.23 to 0.97). We did not observe significant differences in other outcomes.ConclusionThe role of telemedicine in influencing access, quality and efficiency of care in underserved rural hospitals is critically important as these networks become more prevalent in rural healthcare environments.
Background
Cancer survival rates in adolescents and young adults (AYAs) have shown slow improvements in comparison with other age groups, and this may be due to lower participation in clinical ...trials. Little evidence has been provided regarding how nonmetropolitan residence may influence clinical trial enrollment for AYAs with cancer. This study sought to determine whether AYAs from nonmetropolitan areas have lower rates of clinical trial enrollment than their urban counterparts and to examine factors associated with enrollment variation.
Methods
Data from the National Cancer Institute’s 2006 and 2013 Surveillance, Epidemiology, and End Results Patterns of Care AYA cohorts were analyzed. Patients with acute lymphoblastic leukemia, Hodgkin lymphoma, non‐Hodgkin lymphoma, and sarcoma were included (n = 3155). Urban influence codes were used to measure the rurality of the county of residence at diagnosis, which was categorized as large metropolitan, small metropolitan, or nonmetropolitan. Logistic regression compared trial participants and nonparticipants while adjusting for patient and provider factors.
Results
Compared with AYAs from large metropolitan counties, AYAs from small metropolitan (odds ratio OR, 2.04; 95% confidence interval CI, 1.57‐2.64) or nonmetropolitan counties (OR, 1.86; 95% CI, 1.23‐2.81) experienced greater trial enrollment. AYAs treated at a hospital with a residency program (OR, 2.27; 95% CI, 1.63‐3.16) or by a pediatric oncologist (OR, 4.02; 95% CI, 3.03‐5.32) were associated with greater enrollment. There was a significant interaction between rurality and hospital size, which had the greatest impact on nonmetropolitan enrollment.
Conclusions
Clinical trial enrollment was higher among AYAs from nonmetropolitan counties than those from metropolitan counties, predominantly when they were treated at large hospitals.
Clinical trial enrollment is more likely among adolescents and young adults from small metropolitan and nonmetropolitan counties than those from large metropolitan counties. This surprising finding underscores the importance of additional research focused on adolescents and young adults with cancer from nonmetropolitan areas so that factors contributing to clinical trial enrollment and survival disparities can be better understood.
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