Designing for Patient Safety and Efficiency: Simulation-Based Hospital Design Testing.

OBJECTIVE: In the schematic design phase of a new freestanding children's hospital, Simulation-based Hospital Design Testing (SbHDT) was used to evaluate the proposed design of 11 clinical areas. The purpose of this article is to describe the SbHDT process and how it can help identify and mitigate safety concerns during the facility design process. BACKGROUND: In the design of new healthcare facilities, the ability to mitigate risk in the preconstruction period is imperative. SbHDT in a full-scale cardboard mock-up can be used to proactively test the complex interface between people and the built environment. METHOD: This study was a prospective investigation of SbHDT in the schematic design planning phase for a 400-bed freestanding children's hospital where frontline staff simulated episodes of care. Latent conditions related to design were identified through structured debriefing. Failure mode and effect analysis was used to categorize and prioritize simulation findings and was used by the architect team to inform design solutions. A second round of testing was conducted in order to validate design changes. RESULTS: A statistically significant reduction in criticality scores between Round 1 (n = 201, median = 16.14, SD = 5.8) and Round 2 (n = 201, median score of 7.68, SD = 5.26, p < .001) was identified. Bivariate analysis also demonstrated a statistically significant reduction in very high/high criticality scores between Round 1 and Round 2. CONCLUSIONS: SbHDT in the schematic phase of design planning was effective in mitigating risk related to design prototypes through effective identification of latent conditions and validation of design changes.

Frequency and Clinical Features Associated With Eczema Herpeticum in Hospitalized Children With Presumed Atopic Dermatitis Skin Infection.

BACKGROUND: Atopic dermatitis (AD) predisposes to viral skin infections, such as eczema herpeticum (EH), and to bacterial skin infections, such as those caused by Staphylococcus aureus (SA) and group A streptococcus (GAS). This study evaluated clinical features of EH and its frequency of codetection with SA or GAS in children hospitalized for presumed AD skin infection. METHODS: We retrospectively reviewed clinical data for children ≤18 years of age admitted to a large hospital system for AD with presumed skin infection from January 2004 to December 2018. Those with an alternate primary diagnosis or missing microbiologic data were excluded. Encounters with herpes simplex virus testing were identified as AD with EH (ADEH+) or without (ADEH-). Encounters with bacterial skin culture growth were identified as SA or GAS. RESULTS: Among 180 AD encounters with suspected skin infection, 133 (74%) were tested for herpes simplex virus. Clinical findings associated with ADEH+ status (n = 61) included fever on admission (59% vs. 32% in ADEH-; P = 0.002), rash on the neck (30% vs. 13%; P = 0.015) and vesicular rash (70% vs. 49%; P = 0.011). Encounters in the ADEH+ group had a longer hospital length of stay compared with encounters in the ADEH- group [median 4 days (interquartile range 3-5 days) vs. 3 days (interquartile range 2-3 days); P < 0.001]. GAS was identified in only 1 ADEH+ encounter (2%) versus 15 ADEH- encounters (26%), P < 0.001. CONCLUSIONS: Providers should maintain a high index of suspicion for EH in children admitted for presumed AD skin infection. GAS was more commonly associated with ADEH- encounters.

Insurance Receipt and Readiness for Opportunities under the Affordable Care Act: A National Survey of Treatment Providers for Substance Use Disorders.

This study measures the readiness of substance use disorder (SUD) treatment to use opportunities under the Affordable Care Act by examining Medicaid and private insurance acceptance between 2011 and 2013, as well as center characteristics associated with acceptance. Data for this study were from a random sample of SUD treatment centers in the United States. Interviews were conducted on site and face to face, with administrative and clinical directors. We employed logistic regression analyses to examine Medicaid acceptance and private insurance acceptance. We found that 59% of centers accepted Medicaid and 55% accepted private insurance. Accredited centers were more likely to accept Medicaid. A 12-step orientation and greater reliance on female clients were negatively associated with Medicaid acceptance. Larger centers and centers with a greater percentage of counselors with advanced degrees had greater odds of accepting private insurance. Centers that offered residential treatment had lower odds of accepting either Medicaid or private insurance. For private insurance acceptance, having a specific track for homeless patients lowered the odds of acceptance, as did having a greater percentage of Hispanic clients. Newly insured individuals under the ACA may have difficulty finding a program that accepts insurance. Future research should examine effects of Medicaid expansion on SUD treatment delivery.

Counselor training and attitudes toward pharmacotherapies for opioid use disorder.

BACKGROUND: Methadone and buprenorphine have been demonstrated to be effective in the treatment of opioid use disorder (OUD), especially when combined with psychosocial treatment. Despite buprenorphine's association with fewer withdrawal symptoms and lessened risk of abuse, compared with methadone, its adoption remains limited. Given the vital role that counselors may play in its successful implementation, their knowledge and perceptions of opioid agonist therapy may be facilitators or barriers to its acceptance. METHODS: Informed by diffusion theory, the current study examined perceptions of buprenorphine's and methadone's acceptability among 725 counselors employed in a nationally representative sample of substance use disorder treatment centers. First, we provided descriptive statistics about medication diffusion, extent of training received about the medications, and perceptions of acceptability of each medication. Then, we compared acceptability of opioid agonists with other treatment approaches for OUD. Finally, we conducted 2 ordinary least squares regressions to examine counselor acceptability of buprenorphine and of methadone. RESULTS: Descriptive statistics suggested that diffusion of information about buprenorphine and methadone was not complete, and training was not extensive for either medication. Counselors reported greater acceptability and training of buprenorphine compared with methadone. Methadone was rated as the least acceptable among all other treatment approaches. Multivariate analyses indicated regional differences, and that medication-specific training, adaptability, and educational attainment were positively related with perceptions of acceptability of either medication, even after controlling for organizational characteristics. Adherence to a 12-step orientation was negatively associated with acceptability. CONCLUSIONS: Dissemination of information about opioid agonist therapy is occurring. Nevertheless, the fact that 20% of counselors admitted not knowing enough about either buprenorphine's or methadone's effectiveness is surprising in light of the extensive literature documenting their effectiveness. Future research should focus upon different types of training that can inform physicians, counselors, and patients about the use of opioid agonist therapy.

Treatment strategy profiles in substance use disorder treatment programs: A latent class analysis.

BACKGROUND: Modern treatment options for substance use disorder are diverse. While studies have analyzed the adoption of individual evidence-based practices in treatment centers, little is known about the specific make-up of treatment strategy profiles in treatment centers throughout the United States. The current study used latent class analysis to profile underlying treatment strategies and to evaluate philosophical and structural supports associated with each profile. METHODS: Utilizing three aggregated and secondary datasets of nationally representative samples of substance use disorder treatment centers (N=775), we employed latent class analysis to determine treatment strategy profiles. Using multinomial logistic regression, we then examined organizational characteristics associated with each profile. RESULTS: We found three distinct treatment strategy profiles: centers that primarily relied on motivational interviewing and motivational enhancement therapy, centers that utilized psychosocial and alternative therapies, and centers that employed comprehensive treatments including pharmacotherapy. The multinomial logistic regression revealed that philosophical and structural center characteristics were associated with membership in the comprehensive class. Centers with philosophical orientations conducive to holistic care and pharmacotherapy-acceptance, resource-rich infrastructures, and an entrepreneurial reliance on insured clients were more likely to offer diverse interventions. All associations were significant at the .05 level. PRINCIPLE CONCLUSION: The findings from this study help us understand the general strategies of treatment centers. From a practical perspective, practitioners and clients should be aware of the variation in treatment center practices where they may offer or receive treatment.

The use of art and music therapy in substance abuse treatment programs.

Although the implementation of evidence-based practices in the treatment of substance use disorders has attracted substantial research attention, little consideration has been given to parallel implementation of complementary and alternative medical (CAM) practices. Using data from a nationally representative sample (N = 299) of U.S. substance abuse treatment programs, this study modeled organizational factors falling in the domains of patient characteristics, treatment ideologies, and structural characteristics, associated with the use of art therapy and music therapy. We found that 36.8% of treatment programs offered art therapy and 14.7% of programs offered music therapy. Programs with a greater proportion of women were more likely to use both therapies, and programs with larger proportions of adolescents were more likely to offer music therapy. In terms of other treatment ideologies, programs' use of Motivational Enhancement Therapy was positively related to offering art therapy, whereas use of contingency management was positively associated with offering music therapy. Finally, our findings showed a significant relationship between requiring 12-step meetings and the use of both art therapy and music therapy. With increasing use of CAM in a diverse range of medical settings and recent federal legislation likely to reduce barriers in accessing CAM, the inclusion of CAM in addiction treatment is growing in importance. Our findings suggest treatment programs may be utilizing art and music therapies to address unique patient needs of women and adolescents.

The effect of neighborhood disadvantage, social ties, and genetic variation on the antisocial behavior of African American women: a multilevel analysis.

Social disorganization theory posits that individuals who live in disadvantaged neighborhoods are more likely to engage in antisocial behavior than are those who live in advantaged neighborhoods and that neighborhood disadvantage asserts this effect through its disruptive impact on social ties. Past research on this framework has been limited in two respects. First, most studies have concentrated on adolescent males. In contrast, the present study focused on a sample of adult African American females. Second, past research has largely ignored individual-level factors that might explain why people who grow up in disadvantaged neighborhoods often do not engage in antisocial behavior. We investigated the extent to which genetic variation contributes to heterogeneity of response to neighborhood conditions. We found that the impact of neighborhood disadvantage on antisocial behavior was mediated by neighborhood social ties. Further, the analysis indicated that the effects of neighborhood disadvantage and social ties on antisocial behavior were moderated by genetic polymorphisms. Examination of these moderating effects provided support for the differential susceptibility model of Gene × Environment. The effect of Gene × Neighborhood Disadvantage on antisocial behavior was mediated by the effect of Gene × Neighborhood Social Ties, providing support for an expanded view of social disorganization theory.

Gender equality and violent behavior: how neighborhood gender equality influences the gender gap in violence.

Using a sample of 703 African American adolescents from the Family and Community Health Study (FACHS) along with census data from the year 2000, we examine the association between neighborhood-level gender equality and violence. We find that boys' and girls' violent behavior is unevenly distributed across neighborhood contexts. In particular, gender differences in violent behavior are less pronounced in gender-equalitarian neighborhoods compared to those characterized by gender inequality. We also find that the gender gap narrows in gender-equalitarian neighborhoods because boys' rates of violence decrease whereas girls' rates remain relatively low across neighborhoods. This is in stark contrast to the pessimistic predictions of theorists who argue that the narrowing of the gender gap in equalitarian settings is the result of an increase in girls' violence. In addition, the relationship between neighborhood gender equality and violence is mediated by a specific articulation of masculinity characterized by toughness. Our results provide evidence for the use of gender-specific neighborhood prevention programs.