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March 20, 2017
Background: The wide variety of dissemination and implementation designs now being used to evaluate and improve health systems and outcomes warrants review of the scope, features, and limitations of these designs. Methods: This paper is one product of a design workgroup formed in 2013 by the National Institutes of Health to address dissemination and implementation research, and whose members represented diverse methodologic backgrounds, content focus areas, and health sectors. These experts integrated their collective knowledge on dissemination and implementation designs with searches of published evaluations strategies. Results: This paper emphasizes randomized and non-randomized designs for the traditional translational research continuum or pipeline, which builds on existing efficacy and effectiveness trials to examine how one or more evidence-based clinical/prevention interventions are adopted, scaled up, and sustained in community or service delivery systems. We also mention other designs, including hybrid designs that combine effectiveness and implementation research, quality improvement designs for local knowledge, and designs that use simulation modeling.
Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients| January 1, 2017
BACKGROUND: Although nurses are the most likely first responders to witness an in-hospital cardiac arrest (IHCA) and provide treatment, little research has been undertaken to determine what features of nursing are related to cardiac arrest outcomes.
OBJECTIVES: To determine the association between nurse staffing, nurse work environments, and IHCA survival.
RESEARCH DESIGN: Cross-sectional study of data from: (1) the American Heart Association's Get With The Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and and Patient Safety; and (3) the American Hospital Association annual survey. Logistic regression models were used to determine the association of the features of nursing and IHCA survival to discharge after adjusting for hospital and patient characteristics.
SUBJECTS: A total of 11,160 adult patients aged 18 and older between 2005 and 2007 in 75 hospitals in 4 states (Pennsylvania, Florida, California, and New Jersey).
RESULTS: Each additional patient per nurse on medical-surgical units was associated with a 5% lower likelihood of surviving IHCA to discharge (odds ratio=0.95; 95% confidence interval, 0.91-0.99). Further, patients cared for in hospitals with poor work environments had a 16% lower likelihood of IHCA survival (odds ratio=0.84; 95% confidence interval, 0.71-0.99) than patients cared for in hospitals with better work environments.
CONCLUSIONS: Better work environments and decreased patient-to-nurse ratios on medical-surgical units are associated with higher odds of patient survival after an IHCA. These results add to a large body of literature suggesting that outcomes are better when nurses have a more reasonable workload and work in good hospital work environments. Improving nurse working conditions holds promise for improving survival following IHCA.
The Importance of Partnerships in Local Health Department Practice among Communities with Exceptional Maternal and Child Health Outcomes| November 1, 2016
OBJECTIVES: The purpose of this study was to identify unique practices underway in communities that have been empirically identified as having achieved exceptional maternal and child health (MCH) outcomes compared with their peers.
METHODS: We used a qualitative, positive deviance approach to identify practices implemented by local health department (LHD) jurisdictions in Florida, Washington, and New York that achieved better MCH outcomes than expected compared with their in-state peer jurisdictions. We identified a total of 50 LHDs in jurisdictions that had better than expected MCH outcomes compared with their peers, and we conducted 39 hour-long semistructured interviews with LHD staff. We conducted inductive thematic analysis to identify key themes and subthemes across all LHD cases in the sample.
RESULTS: Partnerships with providers, partnerships for data collection/assessment, and partnerships with community-based organizations were associated with exceptional MCH outcomes based on our interviews.
DISCUSSION: This study offers specific examples of practices LHDs can implement to improve MCH outcomes, even with limited resources, based on the practices of high-performing local health jurisdictions.
October 31, 2016
Objective: Trauma exposure can precipitate acute/post-traumatic stress responses (AS/PTSD) and disabling cardiovascular disorders (CVD). Identifying acute stress-related physiologic changes that may increase CVD risk could inform development of early CVD-prevention strategies. The endocannabinoid system (ECS) regulates hypothalamic-pituitary-adrenal (HPA) axis response and stress-related cardiovascular function. We examine stress-related endocannabinoid system (ECS) activity and its association with cardiovascular biochemistry/function following acute stress.
Methods: Rodents (n=8-16/group) were exposed to predator odor or saline; elevated plus maze (EPM), blood pressure (BP), serum and cardiac tissue ECS markers, and lipid metabolism were assessed at 24h and 2wks post-exposure.
Results: At 24h the predator odor group demonstrated anxiety-like behavior and had (a) elevated serum markers of cardiac failure/damage (brain natriuretic peptide [BNP]: 275.1 vs. 234.6, p=0.007; troponin-I: 1.50 vs. 0.78, p=0.076), lipogenesis (triacylglycerols [TAG]: 123.5 vs. 85.93, p=0.018), and inflammation (stearoyl delta-9 desaturase activity [SCD-16]: 0.21 vs. 0.07, p<0.001); (b) significant decrease in cardiac endocannabinoid (2-arachidonoyl-sn-glycerol, 2-AG: 29.90 vs. 65.95, p<0.001) and fatty acid ethanolamides (FAE: oleoylethanolamide, OEA: 114.3 vs. 125.4, p=0.047; palmitoylethanolamide, PEA: 72.96 vs. 82.87, p=0.008); and (c) increased cardiac inflammation (IL-1β/IL-6 ratio: 19.79 vs.13.57, p=0.038; TNF-α/IL-6 ratio: 1.73 vs. 1.03, p=0.019) and oxidative stress (thiobarbituric acid reactive substances [TBARS]: 7.81 vs. 7.05, p=0.022), that were associated with cardiac steatosis (higher TAG: 1.09 vs. 0.72, p<0.001). Cardiac lipogenesis persisted, and elevated BP emerged two weeks after exposure.
Conclusions: Acute psychological stress elicits ECS-related cardiac responses associated with persistent, potentially-pathological changes in rat cardiovascular biochemistry/function.
A Theory-Based Decision Aid for Patients with Cancer: Results of Feasibility and Acceptability Testing of DecisionKEYS for Cancer| October 28, 2016
PURPOSE: Appropriate utilization of treatment is a goal for all patients undergoing cancer treatment. Proper treatment maximizes benefit and limits exposure to unnecessary measures. This report describes findings of the feasibility and acceptability of implementing a short, clinic-based decision aid and presents an in-depth clinical profile of the participants.
METHODS: This descriptive study used a prospective, quantitative approach to obtain the feasibility and acceptability of a decision aid (DecisionKEYS for Balancing Choices) for use in clinical settings. It combined results of trials of patients with three different common malignancies. All groups used the same decision aid series. Participants included 80 patients with solid tumors (22 with newly diagnosed breast cancer, 19 with advanced prostate cancer, and 39 with advanced lung cancer) and their 80 supporters as well as their physicians and nurses, for a total of 160 participants and 10 health professionals.
RESULTS: The decision aid was highly acceptable to patient and supporter participants in all diagnostic groups. It was feasible for use in clinic settings; the overall value was rated highly. Of six physicians, all found the interactive format with the help of the nurse as feasible and acceptable. Nurses also rated the decision aid favorably.
CONCLUSIONS: This intervention provides the opportunity to enhance decision making about cancer treatment and warrants further study including larger and more diverse groups. Strengths of the study included a theoretical grounding, feasibility testing of a practical clinic-based intervention, and summative evaluation of acceptability of the intervention by patient and supporter pairs. Further research also is needed to test the effectiveness of the decision aid in diverse clinical settings and to determine if this intervention can decrease overall costs.