Doyanne Darnell

A randomized evaluation of motivational interviewing training for mandated implementation of alcohol screening and brief intervention in trauma centers

The American College of Surgeons has mandated that level I and level II trauma centers implement universal alcohol screening and brief intervention (SBI) for injured patients. This study was a secondary analysis of a national, 20-hospital, cluster-randomized implementation trial focusing on practical issues of training and supervising alcohol SBI providers in motivational interviewing (MI). The purpose of this study was to examine whether real-world trauma center providers can be trained to provide higher quality counseling using MI as part of brief interventions for alcohol and whether MI skills can be maintained over time. Sites were randomly assigned to receive a 1day workshop training in MI for alcohol SBI or not, and all providers regardless of training completed up to seven standardized patient assessments of MI fidelity over 27months. Six domains on the Motivational Interviewing Treatment Integrity (MITI) coding system were assessed and compared to proficiency criteria. Providers in the intervention training group showed substantially improved MITI scores over the course of the 27-month time period. Domains that had particularly strong improvement were MI spirit and empathy; however, despite the overall improvement in the intervention group scores, expert-derived proficiency criteria were attained only for the global scores. Routine trauma center providers who receive MI training can deliver higher quality counseling in alcohol brief interventions, but may not, however, attain previously derived proficiency standards. Future implementation efforts in real-world acute care medical settings could further elucidate provider characteristics that predict training response and also strive to demonstrate that higher quality alcohol SBI implementation is associated with improved patient-level outcomes.

Technology-Enhanced Stepped Collaborative Care Targeting Posttraumatic Stress Disorder and Comorbidity After Injury: A Randomized Controlled Trial

Posttraumatic stress disorder (PTSD) and its comorbidities are endemic among injured trauma survivors. Previous collaborative care trials targeting PTSD after injury have been effective, but they have required intensive clinical resources. The present pragmatic clinical trial randomized acutely injured trauma survivors who screened positive on an automated electronic medical record PTSD assessment to collaborative care intervention (n = 60) and usual care control (n = 61) conditions. The stepped measurement-based intervention included care management, psychopharmacology, and psychotherapy elements. Embedded within the intervention were a series of information technology (IT) components. PTSD symptoms were assessed with the PTSD Checklist at baseline prerandomization and again, 1-, 3-, and 6-months postinjury. IT utilization was also assessed. The technology-assisted intervention required a median of 2.25 hours (interquartile range = 1.57 hours) per patient. The intervention was associated with modest symptom reductions, but beyond the margin of statistical significance in the unadjusted model: F(2, 204) = 2.95, p = .055. The covariate adjusted regression was significant: F(2, 204) = 3.06, p = .049. The PTSD intervention effect was greatest at the 3-month (Cohens effect size d = 0.35, F(1, 204) = 4.11, p = .044) and 6-month (d = 0.38, F(1, 204) = 4.10, p = .044) time points. IT-enhanced collaborative care was associated with modest PTSD symptom reductions and reduced delivery times; the intervention model could potentially facilitate efficient PTSD treatment after injury.

Within-Provider Variability in Motivational Interviewing Integrity for Three Years after MI Training: Does Time Heal?

This study examined variability in Motivational Interviewing (MI) integrity among 15 providers for three years following training. Data come from an effectiveness trial in which providers were trained to deliver brief single-session MI interventions. Each session was audio-recorded and coded for MI integrity using the Motivational Interviewing Treatment Integrity (MITI) 3.1.1 rating system. Within-provider variation in MI integrity was large, especially for behavior count scores (e.g., open questions, complex reflections) and only slightly smaller for global session scores of MI Spirit and Empathy. Within-provider variability was in most cases larger than between-provider variability and there was no evidence that providers improved appreciably over time. These findings raise concerns about the quality of MI being delivered in large-scale implementation efforts and have implications for the monitoring and training of higher quality MI.

Comparing the Motivational Interviewing integrity in two prevalent models of brief intervention service delivery for primary care settings

This quasi experimental study compared the motivational interviewing (MI) integrity in two prevalent brief intervention (BI) service delivery models for drug abuse. Routine primary care providers (RCPs) and non-routine care providers (NRCPs) performed BIs using an MI style within the same medical setting, patient population, and Screening, Brief Intervention, and Referral for Treatment (SBIRT) protocol. Interventionists (9 RCPs and 6 NRCPs) underwent similar MI training and performed a total of 423 audiorecorded BIs. We compared the MI integrity scores for all audio recorded sessions from these two SBIRT models for up to 40 months post MI training. Both groups met the lower standard (beginning proficiency in MI) on 4 of 5 MI integrity scores, but NRCPs met more of the higher standards (competency in MI) than RCPs. There may be limitations with regards to MI fidelity when using RCPs to conduct BIs in some primary care settings. Further experimental investigation is warranted to replicate this finding and identify casual factors of observed differences in MI fidelity.

Factors Associated With Follow-Up Attendance Among Rape Victims Seen in Acute Medical Care

Objective: Rape is associated with posttraumatic stress disorder (PTSD) and related comorbidities. Most victims do not obtain treatment for these conditions. Acute care medical settings are well positioned to link patients to services; however, difficulty engaging victims and low attendance at provided follow-up appointments is well documented. Identifying factors associated with follow-up can inform engagement and linkage strategies. Method: Administrative, patient self-report, and provider observational data from Harborview Medical Center were combined for the analysis. Using logistic regression, we examined factors associated with follow-up health service utilization after seeking services for rape in the emergency department. Results: Of the 521 diverse female (n = 476) and male (n = 45) rape victims, 28% attended the recommended medical/counseling follow-up appointment. In the final (adjusted) logistic regression model, having a developmental or other disability (OR = 0.40, 95% CI = 0.21–0.77), having a current mental illness (OR = 0.25, 95% CI = 0.13–0.49), and being assaulted in public (OR = 0.50, 95% CI = 0.28–0.87) were uniquely associated with reduced odds of attending the follow-up. Having a prior mental health condition (OR = 3.02, 95% CI = 1.86–4.91), a completed Sexual Assault Nurse Examiner’s (SANE) examination (OR = 2.97, 95% CI = 1.84–4.81), and social support available to help cope with the assault (OR = 3.54, 95% CI = 1.76–7.11) were associated with an increased odds of attending the follow-up. Conclusions: Findings point to relevant characteristics ascertained at the acute care medical visit for rape that may be used to identify victims less likely to obtain posttraumatic medical and mental health services. Efforts to improve service linkage for these patients is warranted and may require alternative service delivery models that engage rape survivors and support posttraumatic recovery.

A content analysis of dissemination and implementation science resource initiatives: what types of resources do they offer to advance the field?

BackgroundThe recent growth in organized efforts to advance dissemination and implementation (D & I) science suggests a rapidly expanding community focused on the adoption and sustainment of evidence-based practices (EBPs). Although promising for the D & I of EBPs, the proliferation of initiatives is difficult for any one individual to navigate and summarize. Such proliferation may also result in redundant efforts or missed opportunities for participation and advancement. A review of existing D & I science resource initiatives and their unique merits would be a significant step for the field. The present study aimed to describe the global landscape of these organized efforts to advance D & I science.MethodsWe conducted a content analysis between October 2015 and March 2016 to examine resources and characteristics of D & I science resource initiatives using public, web-based information. Included resource initiatives must have engaged in multiple efforts to advance D & I science beyond conferences, offered D & I science resources, and provided content in English. The sampling method included an Internet search using D & I terms and inquiry among internationally representative D & I science experts. Using a coding scheme based on a priori and grounded approaches, two authors consensus coded website information including interactive and non-interactive resources and information regarding accessibility (membership, cost, competitive application, and location).ResultsThe vast majority (83%) of resource initiatives offered at least one of seven interactive resources (consultation/technical assistance, mentorship, workshops, workgroups, networking, conferences, and social media) and one of six non-interactive resources (resource library, news and updates from the field, archived talks or slides, links pages, grant writing resources, and funding opportunities). Non-interactive resources were most common, with some appearing frequently across resource initiatives (e.g., news and updates from the field).ConclusionFindings generated by this study offer insight into what types of D & I science resources exist and what new resources may have the greatest potential to make a unique and needed contribution to the field. Additional interactive resources may benefit the field, particularly mentorship opportunities and resources that can be accessed virtually. Moving forward, it may be useful to consider strategic attention to the core tenets of D & I science put forth by Glasgow and colleagues to most efficiently and effectively advance the field.

Technology Use, Preferences, and Capacity in Injured Patients at Risk for Posttraumatic Stress Disorder

Objective: This investigation comprehensively assessed the technology use, preferences, and capacity of diverse injured trauma survivors with posttraumatic stress disorder (PTSD) symptoms. Method: A total of 121 patients participating in a randomized clinical trial (RCT) of stepped collaborative care targeting PTSD symptoms were administered baseline one-, three-, and six-month interviews that assessed technology use. Longitudinal data about the instability of patient cell phone ownership and phone numbers were collected from follow-up interviews. PTSD symptoms were also assessed over the course of the six months after injury. Regression analyses explored the associations between cell phone instability and PTSD symptoms. Results: At baseline, 71.9% (n = 87) of patients reported current cell phone ownership, and over half (58.2%, n = 46) of these patients possessed basic cell phones. Only 19.0% (n = 23) of patients had no change in cell phone number or physical phone over the course of the six months postinjury. In regression models that adjusted for relevant clinical and demographic characteristics, cell phone instability was associated with higher six-month postinjury PTSD symptom levels (p < 0.001). Conclusions: Diverse injured patients at risk for the development of PTSD have unique technology use patterns, including high rates of cell phone instability. These observations should be strongly considered when developing technology-supported interventions for injured patients with PTSD.

Caregiver–Youth Communication about Sex in South Africa: The Role of Maternal Child Sexual Abuse History

Much of the research on child sexual abuse focuses on negative outcomes. This brief report explores a potentially protective parenting behavior among black South African female caregivers with and without a child sexual abuse history. Using cross-sectional baseline data, we hypothesized that caregiver child sexual abuse history would be positively associated with caregiver–youth sex communication and this relationship would be strongest for girls. Youth whose caregiver experienced child sexual abuse were more likely to report communicating with their caregiver about sex than youth whose caregivers did not experience child sexual abuse; however, this relation did not hold for caregiver reported communication. Child sexual abuse survivors’ ability and decision to discuss sex with their youth has the potential to protect youth from sexual risk and demonstrates resilience among a group rarely acknowledged for positive parenting practices.

Patient-Centered Care Transitions After Injury Hospitalization: A Comparative Effectiveness Trial

Objective: The investigation aimed to compare two approaches to the delivery of care for hospitalized injury survivors, a patient-centered care transition intervention versus enhanced usual care. Method: This pragmatic comparative effectiveness trial randomized 171 acutely injured trauma survivors with three or more early postinjury concerns and high levels of emotional distress to intervention (I; n = 85) and enhanced usual care control (C; n = 86) conditions. The care transition intervention components included care management that elicited and targeted improvement in patients’ postinjury concerns, 24/7 study team cell phone accessibility, and stepped-up care. Posttraumatic concerns, symptomatic distress, functional status, and statewide emergency department (ED) service utilization were assessed at baseline and over the course of the 12 months after injury. Regression analyses assessed intervention and control group outcome differences over time. Results: Over 80% patient follow-up was attained at each time point. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns expressed when compared to controls longitudinally (Wald chi-square = 11.29, p = 0.01) and at the six-month study time point (C = 74%, I = 53%; Fisher’s exact test, p = 0.02). Comparisons of ED utilization data yielded clinically significant cross-sectional differences (one or more three- to six-month ED visits; C = 30.2%, I = 16.5%, [relative risk (95% confidence interval] C versus I = 2.00 (1.09, 3.70), p = 0.03) that did not achieve longitudinal statistical significance (F (3, 507) = 2.24, p = 0.08). The intervention did not significantly impact symptomatic or functional outcomes. Conclusions: Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons’ clinical guidelines for U.S. trauma care systems.

Proceedings of the Fourth Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2017: implementation mechanisms: what makes implementation work and why? part 1

Proceedings of the Fourth Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2017: implementation mechanisms: what makes implementation work and why? part 1 Cara C. Lewis, Cameo Stanick, Aaron Lyon, Doyanne Darnell, Jill Locke, Ajeng Puspitasari, Brigid R. Marriott, Caitlin N. Dorsey, Madeline Larson, Carrie Jackson, Jordan Thayer, Callie Walsh Bailey, Rebecca Lengnick-Hall, Shannon Dorsey and Sara J. Landes