Publications by authors named "Rinad Beidas"

161 Publications

Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services.

Psychiatr Serv 2021 Apr 15:appips202000209. Epub 2021 Apr 15.

Department of Psychiatry, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (all authors); Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas).

Evidence-based practices (EBPs) are frequently proposed as an approach to close the quality chasm in behavioral health treatment, and many U.S. municipalities are investing in EBPs as a primary way to improve the quality of care delivered to individuals most in need. In this Open Forum, the authors argue that EBPs often cannot be successfully implemented because basic organizational needs are not met in the current fiscal environment. The authors summarize research that supports why EBPs, along with other approaches to improve quality, are likely to fail until there is adequate financing. They also propose a policy and research agenda to ameliorate and address the fiscal challenges inherent in community mental health and substance use services.
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http://dx.doi.org/10.1176/appi.ps.202000209DOI Listing
April 2021

Identifying the effective components of a standardized labor induction protocol: secondary analysis of a randomized, controlled trial.

J Matern Fetal Neonatal Med 2021 Apr 13:1-7. Epub 2021 Apr 13.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Objective: Standardized labor induction protocols utilizing evidence-based active management practices are associated with improved obstetric outcomes. However, these protocols are complex and include multiple components. We aimed to identify which of the individual components of an evidence-based labor induction protocol are most associated with reduced rates of cesarean delivery, maternal morbidity, and neonatal morbidity.

Study Design: This is a secondary analysis of a randomized trial comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based standardized labor induction protocol. For each patient's induction, we assessed adherence to seven components of the protocol. Primary outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed the association of each protocol component with each outcome. Multivariable logistic regression determined independent predictors of each outcome.

Results: The 491 patients enrolled in the randomized trial were included in this analysis. For cesarean delivery, while adherence to four of the seven protocol components was associated with the outcome in bivariate analyses, only adherence to "cervical exams should be performed every 1-2 h in active labor" was associated with reduced cesarean rates when controlling for age, body mass index, and parity. For maternal morbidity, while adherence to "if misoprostol is utilized, it should not be continued beyond 6 doses or 24 h of use" was associated in bivariate analysis, it was no longer associated with the outcome in multivariable analysis. Finally, "cervical exams should be performed every 1-2 h in active labor" and "cervical exams should be performed every 2-4 h in latent labor" were associated with reduced neonatal morbidity both in bivariate analyses as well as when controlling for age, body mass index, and parity.

Conclusions: Within a standardized labor induction protocol, adherence to cervical exams every 1-2 h in active labor was associated with reduced cesarean rate, and adherence to cervical exams every 2-4 h in latent labor, as well as every 1-2 h in active labor is associated with reduced neonatal morbidity. Regular cervical examination during labor induction likely allows for intervention when cervical change is not made. This data warrants further investigation into the optimal frequency of cervical exams during labor induction. Furthermore, an understanding of which components of a complex, evidence-based labor induction protocol are most effective may be helpful for streamlining and education around this protocol as implementation occurs across diverse sites.
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http://dx.doi.org/10.1080/14767058.2021.1909561DOI Listing
April 2021

The Organizational Financial Context of Publicly-Funded Mental Health Clinics: Development and Preliminary Psychometric Evaluation of the Agency Financial Status Scales.

Adm Policy Ment Health 2021 Mar 19. Epub 2021 Mar 19.

Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3rd Floor, 3015, Philadelphia, PA, 19104, USA.

Funding is a major barrier to implementation of evidence-based practices (EBPs) in publicly-funded community mental health clinics (CMHCs). Understanding how best to deploy implementation strategies that address this barrier requires greater clarity on the financial context within agencies. We developed the Agency Financial Status Scales (AFSS) to assess employee perceptions of the level of three hypothesized and theoretical funding related constructs in organizations: (a) perceptions of financial health, (b) financial attitudes toward EBPs, and (c) strategic financial climate. This investigation serves as a preliminary evaluation of this measure. Participants were 239 therapists and 40 supervisors from 25 publicly-funded CMHCs providing outpatient mental health services for young people. Confirmatory factor analysis was used to investigate the latent trait structure of the items. Internal consistency, interrater agreement, concordance between therapists and supervisors, and convergent validity were also examined. A two-factor model measuring perceptions of financial health and strategic financial climate best fit the data. For both of these scales, alpha reliability was acceptable and agreement statistics provided moderate support for aggregation at the organizational level. Analyses supported the convergent validity of the scales. The development and preliminary evaluation of the AFSS is an important first step in understanding the financial context of publicly-funded CMHCs. Though findings from this investigation are promising, additional development and testing are needed to develop a more thorough understanding of the constructs and to improve the validity and reliability of this measure.
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http://dx.doi.org/10.1007/s10488-021-01128-4DOI Listing
March 2021

Community stakeholder preferences for evidence-based practice implementation strategies in behavioral health: a best-worst scaling choice experiment.

BMC Psychiatry 2021 02 4;21(1):74. Epub 2021 Feb 4.

Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Background: Community behavioral health clinicians, supervisors, and administrators play an essential role in implementing new psychosocial evidence-based practices (EBP) for patients receiving psychiatric care; however, little is known about these stakeholders' values and preferences for implementation strategies that support EBP use, nor how best to elicit, quantify, or segment their preferences. This study sought to quantify these stakeholders' preferences for implementation strategies and to identify segments of stakeholders with distinct preferences using a rigorous choice experiment method called best-worst scaling.

Methods: A total of 240 clinicians, 74 clinical supervisors, and 29 administrators employed within clinics delivering publicly-funded behavioral health services in a large metropolitan behavioral health system participated in a best-worst scaling choice experiment. Participants evaluated 14 implementation strategies developed through extensive elicitation and pilot work within the target system. Preference weights were generated for each strategy using hierarchical Bayesian estimation. Latent class analysis identified segments of stakeholders with unique preference profiles.

Results: On average, stakeholders preferred two strategies significantly more than all others-compensation for use of EBP per session and compensation for preparation time to use the EBP (P < .05); two strategies were preferred significantly less than all others-performance feedback via email and performance feedback via leaderboard (P < .05). However, latent class analysis identified four distinct segments of stakeholders with unique preferences: Segment 1 (n = 121, 35%) strongly preferred financial incentives over all other approaches and included more administrators; Segment 2 (n = 80, 23%) preferred technology-based strategies and was younger, on average; Segment 3 (n = 52, 15%) preferred an improved waiting room to enhance client readiness, strongly disliked any type of clinical consultation, and had the lowest participation in local EBP training initiatives; Segment 4 (n = 90, 26%) strongly preferred clinical consultation strategies and included more clinicians in substance use clinics.

Conclusions: The presence of four heterogeneous subpopulations within this large group of clinicians, supervisors, and administrators suggests optimal implementation may be achieved through targeted strategies derived via elicitation of stakeholder preferences. Best-worst scaling is a feasible and rigorous method for eliciting stakeholders' implementation preferences and identifying subpopulations with unique preferences in behavioral health settings.
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http://dx.doi.org/10.1186/s12888-021-03072-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863375PMC
February 2021

Implementation of a calculator to predict cesarean delivery during labor induction: a qualitative evaluation of the clinician perspective.

Am J Obstet Gynecol MFM 2021 Jan 22;3(3):100321. Epub 2021 Jan 22.

Departments of Psychiatry, Medical Ethics and Health Policy, and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Dr Beidas); Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Dr Beidas).

Background: We previously conducted a prospective cohort study (n=1610) demonstrating that the implementation of a validated calculator to predict likelihood of cesarean delivery during labor induction was associated with reduced maternal morbidity, reduced cesarean delivery rate, and improved birth satisfaction.

Objective: To optimize future implementation, we used qualitative interviews to understand the clinician perspective on: (1) the cesarean delivery risk calculator implementation and (2) the mechanisms by which the use of the calculator resulted in the observed improved outcomes.

Study Design: After completion of the prospective study (June 30, 2019), 20 trainees and attending clinicians (including nurse-midwives, obstetrical physicians, and family medicine physicians) at the study site participated in a single, brief semistructured interview from March 1, 2020, to June 30, 2020. Transcriptions were coded using a systematic approach.

Results: Overall, clinicians had favorable perspectives regarding the cesarean delivery risk calculator. Clinicians described the calculator as offering "objective data" and a "standardized snapshot of the labor trajectory." Concerns were raised regarding "overreliance" on calculator output. Barriers to use included time for patient counseling and "awkwardness" around the interactions and perceived patient misunderstanding of the calculator result. Although most senior clinicians (n=8) reported that the calculator did not impact patient management, trainee clinicians (n=12) more often felt that the calculator influenced care at the extremes of cesarean delivery risk. Furthermore, more senior clinicians felt "neutral" regarding any impact of counseling patients on cesarean delivery risk compared with trainee clinicians, who felt that the counseling "built [patient-clinician] trust."

Conclusion: This qualitative evaluation characterized the generally positive clinician perspective around the cesarean delivery risk calculator, while identifying specific facilitators and barriers to implementation. In addition, we elucidated potential mechanisms by which the calculator may have been related to clinician decision making and patient-clinician interactions, leading to reduced maternal morbidity and improved patient birth satisfaction. This information is important as widespread implementation of the cesarean delivery risk calculator begins.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100321DOI Listing
January 2021

Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making.

Implement Sci Commun 2021 Jan 11;2(1). Epub 2021 Jan 11.

Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA.

Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention for youth with posttraumatic stress disorder. An important component of TF-CBT is the trauma narrative (TN), a phase in the intervention in which youth are guided to process the memories, thoughts, and feelings associated with their traumatic experience(s). Previous work has shown that TF-CBT clinicians complete TNs with only half of their clients, yet little is known about what determines TF-CBT clinicians' use of TNs. The behavioral insights literature-an interdisciplinary field studying judgment and decision-making-offers theoretical and empirical tools to conceptualize what drives complex human behaviors and decisions. Drawing from the behavioral insights literature, the present study seeks to understand what determines clinician use of TNs and to generate strategies that target these determinants.

Methods: Through semi-structured qualitative interviews, we sought the perspectives of trained TF-CBT clinicians working in public mental health settings across the city of Philadelphia (N = 17) to understand their decisions to use TNs with clients. We analyzed the qualitative data using a coding approach informed by the behavioral insights literature. We used an iterative process of structured hypothesis generation, aided by a behavioral insights guide, and rapid validation informed by behavioral insights to uncover the determinants of TN use. We then generated implementation strategies that targeted these determinants using the "Easy Attractive Social Timely" framework, a behavioral insights design approach.

Results: We generated and validated three broad themes about what determines clinician implementation of TNs: decision complexity, clinician affective experience, and agency norms. We hypothesized behavioral insights that underlie these implementation determinants and designed a list of nine corresponding behavioral insights strategies that may facilitate TN implementation.

Conclusions: Our study investigated why an effective component of an evidence-based intervention is difficult to implement. We leveraged robust scientific theories and empirical regularities from the behavioral insights literature to understand clinician perspectives on TN implementation. These factors were theoretically linked to implementation strategies. Our work revealed the potential for using behavioral insights in the diagnosis of evidence-based intervention determinants and the design of implementation strategies.
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http://dx.doi.org/10.1186/s43058-020-00105-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802291PMC
January 2021

Intersection of Surging Firearm Sales and COVID-19, Psychological Distress, and Health Disparities in the US-A Call for Action.

JAMA Netw Open 2021 01 4;4(1):e2034017. Epub 2021 Jan 4.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.34017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901141PMC
January 2021

Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis.

J Hosp Med 2021 Jan;16(1):23-30

Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Objective: Continuous pulse oximetry monitoring (cSpO) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO overuse in order to reduce overuse and its associated harms.

Methods: This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO study, a cross-sectional study to establish rates of cSpO in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO use rates to identify barriers and facilitators to addressing cSpO overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach.

Results: Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO use incorporated into electronic order sets, regular education about cSpO in bronchiolitis, and visual reminders may be needed to reduce cSpO utilization. Parental perceptions and individual clinician comfort affect cSpO practice.

Conclusion: We identified barriers and facilitators to deimplementation of cSpO for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO.
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http://dx.doi.org/10.12788/jhm.3535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7768921PMC
January 2021

Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis.

J Hosp Med 2021 Jan;16(1):23-30

Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Objective: Continuous pulse oximetry monitoring (cSpO) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO overuse in order to reduce overuse and its associated harms.

Methods: This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO study, a cross-sectional study to establish rates of cSpO in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO use rates to identify barriers and facilitators to addressing cSpO overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach.

Results: Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO use incorporated into electronic order sets, regular education about cSpO in bronchiolitis, and visual reminders may be needed to reduce cSpO utilization. Parental perceptions and individual clinician comfort affect cSpO practice.

Conclusion: We identified barriers and facilitators to deimplementation of cSpO for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO.
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http://dx.doi.org/10.12788/jhm.3535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7768921PMC
January 2021

How Health Care Workers Wield Influence Through Twitter Hashtags: Retrospective Cross-sectional Study of the Gun Violence and COVID-19 Public Health Crises.

JMIR Public Health Surveill 2021 01 6;7(1):e24562. Epub 2021 Jan 6.

Brown-Lifespan Center for Digital Health, Brown University, Providence, RI, United States.

Background: Twitter has emerged as a novel way for physicians to share ideas and advocate for policy change. #ThisIsOurLane (firearm injury) and #GetUsPPE (COVID-19) are examples of nationwide health care-led Twitter campaigns that went viral. Health care-initiated Twitter hashtags regarding major public health topics have gained national attention, but their content has not been systematically examined.

Objective: We hypothesized that Twitter discourse on two epidemics (firearm injury and COVID-19) would differ between tweets with health care-initiated hashtags (#ThisIsOurLane and #GetUsPPE) versus those with non-health care-initiated hashtags (#GunViolence and #COVID19).

Methods: Using natural language processing, we compared content, affect, and authorship of a random 1% of tweets using #ThisIsOurLane (Nov 2018-Oct 2019) and #GetUsPPE (March-May 2020), compared to #GunViolence and #COVID19 tweets, respectively. We extracted the relative frequency of single words and phrases and created two sets of features: (1) an open-vocabulary feature set to create 50 data-driven-determined word clusters to evaluate the content of tweets; and (2) a closed-vocabulary feature for psycholinguistic categorization among case and comparator tweets. In accordance with conventional linguistic analysis, we used a P<.001, after adjusting for multiple comparisons using the Bonferroni correction, to identify potentially meaningful correlations between language features and outcomes.

Results: In total, 67% (n=4828) of #ThisIsOurLane tweets and 36.6% (n=7907) of #GetUsPPE tweets were authored by health care professionals, compared to 16% (n=1152) of #GunViolence and 9.8% (n=2117) of #COVID19 tweets. Tweets using #ThisIsOurLane and #GetUsPPE were more likely to contain health care-specific language; more language denoting positive emotions, affiliation, and group identity; and more action-oriented content compared to tweets with #GunViolence or #COVID19, respectively.

Conclusions: Tweets with health care-led hashtags expressed more positivity and more action-oriented language than the comparison hashtags. As social media is increasingly used for news discourse, public education, and grassroots organizing, the public health community can take advantage of social media's broad reach to amplify truthful, actionable messages around public health issues.
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http://dx.doi.org/10.2196/24562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790125PMC
January 2021

A rapid pre-implementation evaluation to inform a family engagement navigator program during COVID-19.

Implement Sci Commun 2020 Dec 9;1(1):110. Epub 2020 Dec 9.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.

Background: Innovative models of family engagement and support are needed in the intensive care unit (ICU) during times of restricted visitation such as the COVID-19 pandemic. Limited understanding of the factors affecting the uptake and outcomes of different family support models hinders the implementation of best practices. We aimed to conduct a rapid pre-implementation evaluation of stakeholder-perceived facilitators and barriers to design implementation strategies to support a novel program using medical students to facilitate family-centered care in the ICU.

Methods: We conducted a 2-step process. In step 1, we gathered contextual data via interview-style open-ended questions sent to clinicians and navigator stakeholders via email. We used electronic data collection due to the physical distancing requirements, the need to prioritize brief data collection for respondent burden, and the need for rapid knowledge gain. A codebook based on the Consolidated Framework for Implementation Research (CFIR), an integrated framework from the field of implementation science, was used to analyze the findings. In step 2, a pilot of the intervention was implemented with 3 navigators over 2 weeks. Implementation strategies were developed to target barriers identified by the pre-implementation evaluation.

Results: Fourteen (70%) of the identified stakeholders responded to the survey. Ten constructs encompassing all five CFIR domains were present in responses as implementation influencers, with the Intervention domain most frequently represented. Through these results and operational feedback from navigators during the pilot period, stakeholders selected multiple implementation strategies: audit and provide feedback, develop educational materials, conduct ongoing training, promote adaptability, assess and redesign workflow, identify and prepare champions, and engage community resources.

Conclusions: We demonstrated how a conceptually based pre-implementation program evaluation can be used to rapidly inform optimal implementation strategies. We report key factors to inform design and implementation strategies for a novel ICU family engagement navigator program that may be useful to others wishing to adopt similar programs.
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http://dx.doi.org/10.1186/s43058-020-00098-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724442PMC
December 2020

Expanding the reach of psychological science through implementation science: Introduction to the special issue.

Am Psychol 2020 11;75(8):1033-1037

Perelman School of Medicine, University of Pennsylvania.

Implementation science is the study of methods to promote the systematic uptake of effective practices into routine care settings with the broad goal of ensuring that scientific discoveries realize their potential and improve people's lives. As a field, implementation science includes three primary foci: (a) understanding the context in which individuals will implement practices that have a strong, established evidence base; (b) developing implementation approaches that target the factors that may accelerate or hinder implementation; and (c) conducting pragmatic trials to test these implementation approaches. Psychological science has contributed substantially to the knowledge and methods used in implementation science. In medicine and public health, these contributions have been leveraged to facilitate the uptake of screening and prevention programs, hand hygiene to reduce infection transmission, and many medical innovations. In behavioral health settings, implementation science has often focused on specific forms of psychotherapy, with emphasis on the evidence-based psychological practices that are highlighted in treatment guidelines. This article provides an overview of the field, with an emphasis on the bidirectional relationship between implementation science, and psychological science, illustrated through the articles in this special issue of the American Psychologist. It concludes with recommendations for future research at the intersection of implementation science and psychological science. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/amp0000774DOI Listing
November 2020

Assessing barriers to providing tobacco use disorder treatment in community mental health settings with a revised version of the Smoking Knowledge, Attitudes, and Practices (S-KAP) instrument.

Addict Behav 2021 03 19;114:106735. Epub 2020 Nov 19.

Department of Psychiatry, University of Pennsylvania, United States.

Background: Tobacco use disorder (TUD) rates are 2-3 times higher among people with serious mental illness (SMI) than the general population. Clinicians working in outpatient community mental health clinics are well positioned to provide TUD treatment to this group, but rates of treatment provision are very low. Understanding factors associated with the provision of TUD treatment by mental health clinicians is a priority.

Methods: This study used baseline data from an ongoing cluster-randomized clinical trial evaluating two approaches to training clinicians to increase TUD treatment. Following a psychometric assessment of our assessment tool, the Smoking Knowledge, Attitudes, and Practices (S-KAP) instrument, a new factor structure was evaluated utilizing confirmatory factor analysis. Structural equation modeling was then used to examine the associations between TUD treatment practices and clinician, setting, and patient characteristics in a sample of 182 mental health clinicians across 10 mental health clinics.

Results: Clinician but not setting or patient characteristics emerged as significant correlates of providing TUD treatment. Specifically, clinicians' general ethical commitment to providing TUD services and perceptions of their skills in providing this type of care were associated with providing TUD treatment. In contrast, clinician perceptions of patient motivation, anticipated quit rates, or available setting resources were not significantly associated with providing TUD treatment.

Conclusions: Enhancing community mental health clinician TUD treatment skills and commitment to providing such services may reduce TUD rates among people with SMI. Future studies should evaluate interventions that target these factors.
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http://dx.doi.org/10.1016/j.addbeh.2020.106735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785675PMC
March 2021

Integrating implementation science in clinical research to maximize public health impact: a call for the reporting and alignment of implementation strategy use with implementation outcomes in clinical research.

Implement Sci 2020 Nov 25;15(1):103. Epub 2020 Nov 25.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: Although comprehensive reporting guidelines for implementation strategy use within implementation research exist, they are rarely used by clinical (i.e., efficacy and effectiveness) researchers. In this debate, we argue that the lack of comprehensive reporting of implementation strategy use and alignment of those strategies with implementation outcomes within clinical research is a missed opportunity to efficiently narrow research-to-practice gaps.

Main Body: We review ways that comprehensively specifying implementation strategy use can advance science, including enhancing replicability of clinical trials and reducing the time from clinical research to public health impact. We then propose that revisions to frequently used reporting guidelines in clinical research (e.g., CONSORT, TIDieR) are needed, review current methods for reporting implementation strategy use (e.g., utilizing StaRI), provide pragmatic suggestions on how to both prospectively and retrospectively specify implementation strategy use and align these strategies with implementation outcomes within clinical research, and offer a case study of using these methods.

Conclusions: The approaches recommended in this article will not only contribute to shared knowledge and language among clinical and implementation researchers but also facilitate the replication of efficacy and effectiveness research. Ultimately, we hope to accelerate translation from clinical to implementation research in order to expedite improvements in public health.
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http://dx.doi.org/10.1186/s13012-020-01060-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690013PMC
November 2020

Safe Firearm Storage: A Call for Research Informed by Firearm Stakeholders.

Pediatrics 2020 11 9;146(5). Epub 2020 Oct 9.

Firearm Injury & Policy Research Program, Harborview Injury Prevention & Research Center.

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http://dx.doi.org/10.1542/peds.2020-0716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605082PMC
November 2020

Safe Firearm Storage: A Call for Research Informed by Firearm Stakeholders.

Pediatrics 2020 11 9;146(5). Epub 2020 Oct 9.

Firearm Injury & Policy Research Program, Harborview Injury Prevention & Research Center.

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http://dx.doi.org/10.1542/peds.2020-0716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605082PMC
November 2020

Training with tarantulas: A randomized feasibility and acceptability study using experiential learning to enhance exposure therapy training.

J Anxiety Disord 2020 12 17;76:102308. Epub 2020 Sep 17.

Department of Psychology, Temple University, 1701 N 13th St., Philadelphia, PA, 19122, USA.

Background: Although exposure is a key evidence-based intervention for anxiety, it is infrequently used in clinical settings. This study employed a novel training strategy, experiential learning, to improve exposure implementation. This study aimed to assess the feasibility and acceptability of experiential training and preliminary training effectiveness.

Methods: Participants were 28 therapists who were randomized to (a) training-as-usual or (b) experiential training (training-as-usual plus a one-session treatment for fear of spiders). Workshops lasted one day and were followed by three months of weekly consultation.

Results: Experiential training was viewed as feasible and acceptable. Participants, including those who were fearful of spiders, had a positive response to the training and reported it to be useful. There was a significant increase in the number of exposures used by therapists receiving experiential training compared to training-as-usual at 1-month follow-up.

Conclusions: A one-day training resulted in significant improvements in knowledge, attitudes toward exposure, and self-efficacy in using exposure. Preliminary findings suggest that experiential training resulted in greater use of exposure post-training compared to training-as-usual. Results provide evidence for the feasibility and acceptability of experiential training as a strategy to increase the use of evidence-based interventions.
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http://dx.doi.org/10.1016/j.janxdis.2020.102308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680428PMC
December 2020

Harnessing implementation science to optimize harm prevention in critically ill children: A pilot study of bedside nurse CLABSI bundle performance in the pediatric intensive care unit.

Am J Infect Control 2021 03 18;49(3):345-351. Epub 2020 Aug 18.

The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Objective: Central-line associated bloodstream infection (CLABSI) is associated with increased mortality, morbidity, and cost in hospitalized children. An evidence-based bundle of care can decrease CLABSI, but bundle compliance is imperfect. We explored factors impacting bundle performance in the pediatric intensive care unit (PICU) by bedside nurses.

Methods: Single-center cross-sectional electronic survey of PICU bedside nurses in an academic tertiary care center; using the COM-B (capability, opportunity, motivation) and TDF (theoretical domains framework) behavioral models to explore CLABSI bundle performance and identify barriers to compliance.

Results: We analyzed 160 completed surveys from 226 nurses (71% response rate). CLABSI knowledge was strong (capability). However, challenges related to opportunity were identified: 71% reported that patient care requirements impact bundle completion; 32% described the bundle as stressful; and CLABSI was viewed as the most difficult of all bundles. Seventy-five percent reported being highly impacted by physician attitude toward the CLABSI bundle (motivation).

Conclusions: PICU nurses are knowledgeable and motivated to prevent CLABSI, but face challenges from competing clinical tasks, limited resources, and complex family interactions. Physician engagement was specifically noted to impact nurse motivation to complete the bundle. Interventions that address these challenges may improve bundle performance and prevent CLABSI in critically ill children.
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http://dx.doi.org/10.1016/j.ajic.2020.08.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889766PMC
March 2021

Realizing the Promise of Learning Organizations to Transform Mental Health Care: Telepsychiatry Care As an Exemplar.

Psychiatr Serv 2021 01 12;72(1):86-88. Epub 2020 Aug 12.

Departments of Psychiatry, Medical Ethics & Health Policy, and Medicine, Perelman School of Medicine, and Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas); National Center for PTSD, Menlo Park, and Department of Psychiatry and Biobehavioral Sciences, Stanford University, Stanford, California (Wiltsey Stirman).

To address the global mental health crisis exacerbated by the COVID-19 pandemic, an urgent need has emerged to transform the accessibility, efficiency, and quality of mental health care. The next suite of efforts to transform mental health care must foster the implementation of "learning organizations," that is, organizations that continuously improve patient-centered care through ongoing data collection. The concept of learning organizations is highly regarded, but the key features of such organizations, particularly those providing mental health care, are less well defined. Using telepsychiatry care as an example, the authors of this Open Forum concretely describe the key building blocks for operationalizing a learning organization in mental health care to set a research agenda for services transformation.
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http://dx.doi.org/10.1176/appi.ps.202000257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869972PMC
January 2021

Clinical Supervision in Community Mental Health: Characterizing Supervision as Usual and Exploring Predictors of Supervision Content and Process.

Community Ment Health J 2021 Apr 15;57(3):552-566. Epub 2020 Jul 15.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Room 3015, Philadelphia, PA, 19104, USA.

Clinical supervision can be leveraged to support implementation of evidence-based practices in community mental health settings, though it has been understudied. This study focuses on 32 supervisors at 23 mental health organizations in Philadelphia. We describe characteristics of supervisors and organizations and explore predictors of supervision content and process. Results highlight a low focus on evidence-based content and low use of active supervision processes. They underscore the need for further attention to the community mental health context when designing supervision-targeted implementation strategies. Future work should assess whether supervision models specific to community mental health are needed.
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http://dx.doi.org/10.1007/s10597-020-00681-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855099PMC
April 2021

The role of staffing and classroom characteristics on preschool teachers' use of one-to-one intervention with children with autism.

Autism 2020 11 6;24(8):2035-2045. Epub 2020 Jul 6.

University of Pennsylvania, USA.

Lay Abstract: For preschool children with autism, individual (one-to-one) behavioral interventions are among the best-tested treatments. However, they are rarely used in special education preschools. We observed formally and informally delivered one-to-one behavioral interventions use by classroom staff ( = 51) in 12 classrooms across three special education preschools for children with autism, aged 3-6 years, in a major US city. We estimated the associations between one-to-one intervention use and classroom characteristics including staff-student ratio, professional role composition, and frequency of challenging child behaviors. As a whole, the factors we examined were considerably important for both formally and informally delivered one-to-one interventions. The number of individually assigned personal care aides in the classroom was negatively associated with the use of formally delivered one-to-one intervention. Classroom challenging behavior was positively associated with use of formally delivered one-to-one interventions. Interventionist's professional roles and the number of children in the class were most important for the use of informally delivered interventions. Staff training, clarifying professional roles, setting performance expectations for personal care aides and other classroom team members, and reducing class size may represent promising implementation targets. Findings suggest caution around task-shifting policies that transfer clinical functions from more highly trained to less highly trained staff.
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http://dx.doi.org/10.1177/1362361320932726DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853200PMC
November 2020

Digital Mental Health: The Answer to the Global Mental Health Crisis?

JMIR Ment Health 2020 Jun 2;7(6):e18472. Epub 2020 Jun 2.

Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.

Digital mental health interventions are often touted as the solution to the global mental health crisis. However, moving mental health care from the hands of professionals and into digital apps may further isolate individuals who need human connection the most. In this commentary, we argue that people, our society's greatest resource, are as ubiquitous as technology. Thus, we argue that research focused on using technology to support all people in delivering mental health prevention and intervention deserves greater attention in the coming decade.
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http://dx.doi.org/10.2196/18472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298632PMC
June 2020

Where Is the Implementation Science? An Opportunity to Apply Principles During the COVID-19 Pandemic.

Clin Infect Dis 2020 12;71(11):2993-2995

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

The coronavirus disease 2019 pandemic represents a global crisis that has received extraordinary response from healthcare workers and scientists. One critical but potentially overlooked field in a pandemic is implementation science-the study of methods to reduce the research-to-practice gap. In this Viewpoint, we discuss the important role of implementation science during this and future pandemics and highlight considerations to maximize the utility of implementation research.
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http://dx.doi.org/10.1093/cid/ciaa622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314225PMC
December 2020

Does implementing a new intervention disrupt use of existing evidence-based autism interventions?

Autism 2020 10 20;24(7):1713-1725. Epub 2020 May 20.

University of Pennsylvania, USA.

Lay Abstract: Interventions for children with autism spectrum disorder are complex and often are not implemented successfully within schools. When new practices are introduced in schools, they often are layered on top of existing practices, with little attention paid to how introducing new practices affects the use of existing practices. This study evaluated how introducing a computer-assisted intervention, called TeachTown:Basics, affected the use of other evidence-based practices in autism support classrooms. We compared how often teachers reported using a set of evidence-based practices in classrooms that either had access to TeachTown:Basics or did not have the program. We found that teachers who had access to the computer-assisted intervention reported using the other evidence-based practices less often as the school year progressed. Teachers also reported that they liked the computer-assisted intervention, found it easy to use, and that it helped overcome challenges to implementing other evidence-based practices. This is important because the computer-assisted intervention did not improve child outcomes in a previous study and indicates that teachers may use interventions that are appealing and easier to implement, even when they do not have evidence to support their effectiveness. These findings support the idea of interventions' complexity and how well the intervention fits within the classroom affect how teachers use it and highlight the need to develop school-based interventions that both appeal to the practitioner and improve child outcomes.
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http://dx.doi.org/10.1177/1362361320919248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541454PMC
October 2020

Applying NUDGE to Inform Design of EBP Implementation Strategies in Community Mental Health Settings.

Adm Policy Ment Health 2021 01;48(1):131-142

Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

We demonstrate the application of NUDGE (Narrow, Understand, Discover, Generate, Evaluate), a behavioral economics approach to systematically identifying behavioral barriers that impede behavior enactment, to the challenge of evidence-based practice (EBP) use in community behavioral health. Drawing on 65 clinician responses to a system-wide crowdsourcing challenge about EBP underutilization, we applied NUDGE to discover, synthesize and validate specific behavioral barriers to EBP utilization that directly inform the design of tailored implementation strategies. To our knowledge, this is the first study to apply behavioral economic insights to clinician-proposed solutions to implementation challenges in order to design implementation strategies. The study demonstrates the successful application of NUDGE to implementation strategy design and provides novel targets for intervention.
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http://dx.doi.org/10.1007/s10488-020-01052-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092115PMC
January 2021

Early Childhood Sleep Intervention in Urban Primary Care: Caregiver and Clinician Perspectives.

J Pediatr Psychol 2020 09;45(8):933-945

Perelman School of Medicine, University of Pennsylvania.

Background: Despite significant income-related disparities in pediatric sleep, few early childhood sleep interventions have been tailored for or tested with families of lower socio-economic status (SES). This qualitative study assessed caregiver and clinician perspectives to inform adaptation and implementation of evidence-based behavioral sleep interventions in urban primary care with families who are predominantly of lower SES.

Methods: Semi-structured interviews were conducted with (a) 23 caregivers (96% mothers; 83% Black; 65% ≤125% U.S. poverty level) of toddlers and preschoolers with insomnia or insufficient sleep and (b) 22 urban primary care clinicians (physicians, nurse practitioners, social workers, and psychologists; 87% female; 73% White). Guided by the Consolidated Framework for Implementation Research, the interview guide assessed multilevel factors across five domains related to intervention implementation. Qualitative data were analyzed using an integrated approach to identify thematic patterns across participants and domains.

Results: Patterns of convergence and divergence in stakeholder perspectives emerged across themes. Participants agreed upon the importance of child sleep and intervention barriers (family work schedules; household and neighborhood factors). Perspectives aligned on intervention (flexibility; collaborative and empowering care) and implementation (caregiver-to-caregiver support and use of technology) facilitators. Clinicians identified many family barriers to treatment engagement, but caregivers perceived few barriers. Clinicians also raised healthcare setting factors that could support (integrated care) or hinder (space and resources) implementation.

Conclusions: Findings point to adaptations to evidence-based early childhood sleep intervention that may be necessary for effective implementation in urban primary care. Such adaptations could potentially reduce significant pediatric sleep-related health disparities.
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http://dx.doi.org/10.1093/jpepsy/jsaa024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438960PMC
September 2020

Improving the implementation and sustainment of evidence-based practices in community mental health organizations: a study protocol for a matched-pair cluster randomized pilot study of the Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS).

Implement Sci Commun 2020 25;1. Epub 2020 Feb 25.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Implementing and sustaining evidence-based programs with fidelity may require multiple implementation strategies tailored to address multi-level, context-specific barriers and facilitators. Ideally, selecting and tailoring implementation strategies should be guided by theory, evidence, and input from relevant stakeholders; however, methods to guide the selection and tailoring of strategies are not well-developed. There is a need for more rigorous methods for assessing and prioritizing implementation determinants (barriers and facilitators) and linking implementation strategies to determinants. The Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS) is an intervention designed to increase the effectiveness of evidence-based practice implementation and sustainment. COAST-IS will enable organizational leaders and clinicians to use Intervention Mapping to select and tailor implementation strategies to address their site-specific needs. Intervention Mapping is a multi-step process that incorporates theory, evidence, and stakeholder perspectives to ensure that implementation strategies effectively address key determinants of change.

Methods: COAST-IS will be piloted with community mental health organizations that are working to address the needs of children and youth who experience trauma-related emotional or behavioral difficulties by engaging in a learning collaborative to implement an evidence-based psychosocial intervention (trauma-focused cognitive behavioral therapy). Organizations will be matched and then randomized to participate in the learning collaborative only (control) or to receive additional support through COAST-IS. The primary aims of this study are to (1) assess the acceptability, appropriateness, feasibility, and perceived utility of COAST-IS; (2) evaluate the organizational stakeholders' fidelity to the core elements of COAST-IS; and (3) demonstrate the feasibility of testing COAST-IS in a larger effectiveness trial.

Discussion: COAST-IS is a systematic method that integrates theory, evidence, and stakeholder perspectives to improve the effectiveness and precision of implementation strategies. If effective, COAST-IS has the potential to improve the implementation and sustainment of a wide range of evidence-based practices in mental health and other sectors.

Trial Registration: This study was registered in ClinicalTrials.gov (NCT03799432) on January 10, 2019 (last updated August 5, 2019).
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http://dx.doi.org/10.1186/s43058-020-00009-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207049PMC
February 2020