PDF(Pubmed)
Abstract：
UNASSIGNED: Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers.
UNASSIGNED: Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9).
UNASSIGNED: After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate.
UNASSIGNED: Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.
While many implementation theories espouse the importance of organizational culture and climate for the successful implementation of evidence-based practices in primary care, there is little research that tests this hypothesis. Since there are interventions which can improve organizational culture and climate, having more evidence that these factors are associated with implementation would support efforts to modify these aspects of a community health center as a means of improving implementation. This study showed that the extent to which patients clinically benefitted from the evidence-based Collaborative Care Model for maternal depression was related to the prevailing culture and climate of community health centers where they received treatment. Specifically, women seen at centers in which the staff and providers indicated that their organizations prioritize responsiveness to patients’ needs over competing organizational goals and maintain competence in up-to-date treatment models (referred to as proficient culture), and understand their role in the organization and receive the cooperation and support they need from colleagues and supervisors to perform their job well (functional climate) were associated with sustained improvements in depression symptoms. This benefit was independent of other factors already known to be associated with these outcomes. Implementation strategies that target organizational culture (i.e., priorities and expectations for staff) and climate (i.e., quality of working environment) may improve the clinical outcomes of integrated collaborative care models for depression and reduce the commonly seen variation in outcomes across health centers.
UNASSIGNED: Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9).
UNASSIGNED: After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate.
UNASSIGNED: Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.
While many implementation theories espouse the importance of organizational culture and climate for the successful implementation of evidence-based practices in primary care, there is little research that tests this hypothesis. Since there are interventions which can improve organizational culture and climate, having more evidence that these factors are associated with implementation would support efforts to modify these aspects of a community health center as a means of improving implementation. This study showed that the extent to which patients clinically benefitted from the evidence-based Collaborative Care Model for maternal depression was related to the prevailing culture and climate of community health centers where they received treatment. Specifically, women seen at centers in which the staff and providers indicated that their organizations prioritize responsiveness to patients’ needs over competing organizational goals and maintain competence in up-to-date treatment models (referred to as proficient culture), and understand their role in the organization and receive the cooperation and support they need from colleagues and supervisors to perform their job well (functional climate) were associated with sustained improvements in depression symptoms. This benefit was independent of other factors already known to be associated with these outcomes. Implementation strategies that target organizational culture (i.e., priorities and expectations for staff) and climate (i.e., quality of working environment) may improve the clinical outcomes of integrated collaborative care models for depression and reduce the commonly seen variation in outcomes across health centers.
摘要：
■组织因素可能有助于通过实施和维持来解释循证临床创新的有效性差异。这项研究测试了在社区卫生中心实施的合作护理模式（CoCM）治疗孕产妇抑郁症的组织文化与气候之间的关系以及临床结果的变化。
■使用组织社会背景（OSC）措施评估了10个社区健康中心的组织文化和气候，这些中心为怀孕或育儿的低收入妇女提供了CoCM。三级分层线性模型测试了N=468名接受护理±1年OSC评估的女性的文化和气候变化是否预示了抑郁症状从基线到基线后6.5个月的改善。使用患者健康问卷（PHQ-9）测量抑郁症症状学。
■在控制患者特征后，案例混合,中心尺寸,和实施支持，与培养水平较低的中心相比，培养水平较高的中心服务的患者从基线到基线后6.5个月的改善幅度更大（平均改善=5.08vs.分别为0.14，p=.020)，导致dadj=0.78的大调整效果大小。对于具有更多功能气候的中心服务的患者观察到类似的效果（平均改善=5.25vs.1.12，p<.044，dadj=0.65）。生长模型表明，所有中心的患者在护理4个月后平均康复。然而,培养水平较高的患者在基线后6.5个月时仍保持稳定,而由培养水平较低的中心提供服务的患者则恶化.对于功能性气候也观察到了类似的模式。
■接受母亲抑郁症协作护理的历史上服务不足人群的女性临床结局差异与社区卫生中心的组织文化和气候有关。针对文化和气候的实施策略可以改善抑郁症综合行为保健的实施和有效性。
虽然许多实施理论主张组织文化和气候对于在初级保健中成功实施循证实践的重要性，很少有研究来检验这个假设。由于有干预措施可以改善组织文化和气候，有更多的证据表明这些因素与实施相关，将支持努力修改社区卫生中心的这些方面，作为改进实施的一种手段。这项研究表明，患者在临床上从基于证据的母亲抑郁症协作护理模式中受益的程度与他们接受治疗的社区卫生中心的流行文化和气候有关。具体来说,在中心的工作人员和提供者表示，他们的组织优先考虑对患者需求的反应，而不是相互竞争的组织目标，并保持最新治疗模式的能力（称为精通文化），了解他们在组织中的角色，并从同事和主管那里获得他们需要的合作和支持，以良好地执行他们的工作（功能氛围）与抑郁症状的持续改善有关。这种益处独立于已知与这些结果相关的其他因素。以组织文化为目标的实施战略(即，员工的优先事项和期望)和气候(即，工作环境的质量）可能会改善抑郁症综合协作护理模式的临床结果，并减少医疗中心常见的结果差异。
■使用组织社会背景（OSC）措施评估了10个社区健康中心的组织文化和气候，这些中心为怀孕或育儿的低收入妇女提供了CoCM。三级分层线性模型测试了N=468名接受护理±1年OSC评估的女性的文化和气候变化是否预示了抑郁症状从基线到基线后6.5个月的改善。使用患者健康问卷（PHQ-9）测量抑郁症症状学。
■在控制患者特征后，案例混合,中心尺寸,和实施支持，与培养水平较低的中心相比，培养水平较高的中心服务的患者从基线到基线后6.5个月的改善幅度更大（平均改善=5.08vs.分别为0.14，p=.020)，导致dadj=0.78的大调整效果大小。对于具有更多功能气候的中心服务的患者观察到类似的效果（平均改善=5.25vs.1.12，p<.044，dadj=0.65）。生长模型表明，所有中心的患者在护理4个月后平均康复。然而,培养水平较高的患者在基线后6.5个月时仍保持稳定,而由培养水平较低的中心提供服务的患者则恶化.对于功能性气候也观察到了类似的模式。
■接受母亲抑郁症协作护理的历史上服务不足人群的女性临床结局差异与社区卫生中心的组织文化和气候有关。针对文化和气候的实施策略可以改善抑郁症综合行为保健的实施和有效性。
虽然许多实施理论主张组织文化和气候对于在初级保健中成功实施循证实践的重要性，很少有研究来检验这个假设。由于有干预措施可以改善组织文化和气候，有更多的证据表明这些因素与实施相关，将支持努力修改社区卫生中心的这些方面，作为改进实施的一种手段。这项研究表明，患者在临床上从基于证据的母亲抑郁症协作护理模式中受益的程度与他们接受治疗的社区卫生中心的流行文化和气候有关。具体来说,在中心的工作人员和提供者表示，他们的组织优先考虑对患者需求的反应，而不是相互竞争的组织目标，并保持最新治疗模式的能力（称为精通文化），了解他们在组织中的角色，并从同事和主管那里获得他们需要的合作和支持，以良好地执行他们的工作（功能氛围）与抑郁症状的持续改善有关。这种益处独立于已知与这些结果相关的其他因素。以组织文化为目标的实施战略(即，员工的优先事项和期望)和气候(即，工作环境的质量）可能会改善抑郁症综合协作护理模式的临床结果，并减少医疗中心常见的结果差异。
