BackgroundWe examined the performance of four in-clinic Giardia diagnostic tests by comparing results to three laboratory methods for detection of Giardia. A set of 177 fecal samples originally submitted to a commercial laboratory by veterinarians for routine ova and parasite (O&P) testing was used. Specimens were examined by direct immunofluorescence assay (DFA) for presence of Giardia cysts which served as the gold standard. Fecal samples were tested using a Giardia-specific cyst wall antigen microtiter plate format enzyme-linked immunosorbent assay (ELISA) and each of the in-clinic assays adhering to the package insert for each kit.ResultsEvaluated were four in-clinic antigen test kits: VetScan® Canine Giardia Rapid Test (Abaxis), Anigen® Rapid CPV-CCV-Giardia Antigen Test (BioNote), SNAP® Giardia Test (IDEXX) and Witness® Giardia Test (Zoetis). In the comparison of the in-clinic tests to the DFA standard test sensitivity ranged between 70.0–87.1%, and specificity ranged between 71.1–93.4%.ConclusionOf the tests evaluated here, the SNAP test had the highest sensitivity and specificity. The SNAP test had the highest percent positive and percent negative agreement when compared to the microtiter plate format ELISA and the O&P assay.

Background Few real-world examples exist of how best to select and adapt implementation strategies that promote sustainability. We used a collaborative care (CC) use case to describe a novel, theory-informed, stakeholder engaged process for operationalizing strategies for sustainability using a behavioral lens. Methods Informed by the Dynamic Sustainability Framework, we applied the Behaviour Change Wheel to our prior mixed methods to identify key sustainability behaviors and determinants of sustainability before specifying corresponding intervention functions, behavior change techniques, and implementation strategies that would be acceptable, equitable and promote key tenets of sustainability (i.e., continued improvement, education). Drawing on user-centered design principles, we enlisted 22 national and local stakeholders to operationalize and adapt (e.g., content, functionality, workflow) a multi-level, multi-component implementation strategy to maximally target behavioral and contextual determinants of sustainability. Results After reviewing the long-term impact of early implementation strategies (i.e., external technical support, quality monitoring, and reimbursement), we identified ongoing care manager CC delivery, provider treatment optimization, and patient enrollment as key sustainability behaviors. The most acceptable, equitable, and feasible intervention functions that would facilitate ongoing improvement included environmental restructuring, education, training, modeling, persuasion, and enablement. We determined that a waiting room delivered shared decision-making and psychoeducation patient tool (DepCare), the results of which are delivered to providers, as well as ongoing problem-solving meetings/local technical assistance with care managers would be the most acceptable and equitable multi-level strategy in diverse settings seeking to sustain CC programs. Key adaptations in response to dynamic contextual factors included expanding the DepCare tool to incorporate anxiety/suicide screening, triage support, multi-modal delivery, and patient activation (vs. shared decision making) (patient); pairing summary reports with decisional support and yearly onboarding/motivational educational videos (provider); incorporating behavioral health providers into problem-solving meetings and shifting from billing support to quality improvement and triage (system). Conclusion We provide a roadmap for designing behavioral theory-informed, implementation strategies that promote sustainability and employing user-centered design principles to adapt strategies to changing mental health landscapes.

Introduction: Elevated depressive symptoms in coronary heart disease (CHD) patients increases the risk of recurrent cardiovascular events and mortality. Experts posit that behavioral determinants like physical inactivity, patient activation/healthcare engagement, and depression treatment uptake may mediate this relationship. Social determinants like access to high-resourced/integrated clinical settings have also emerged, independent of patient-level demographics/factors. We sought to examine the impact of social determinants on trends in behavioral risk factors among CHD patients. Methods: As part of a trial of an electronic shared decision-making tool in depressed CHD patients (iHeart DepCare), we recruited English and Spanish-speaking patients with upcoming internal medicine and cardiology clinic appointments in 8 geographically and socioeconomically diverse clusters of clinics in NY from April 2019 to August 2021. Eligible participants were aged ≥21 years with an ICD10 code for CHD and a Patient Health Questionnaire-9 ≥10 but not under psychiatric care. Baseline questionnaires included the patient activation measure, international physical activity questionnaire, and self-reported preferred mental health treatment. We used descriptive statistics and logistic regression to examine pre-post changes in behavioral risk factors (2020-2021 vs. 2019) overall and by system-level resources (6 commercial insured/extensively resourced clinics [high] vs. 2 Medicaid only/limited resources [low]). Results: Of the 627 screened patients, 96 (15.3%) of CHD patients had elevated depressive symptoms; 22.4% in low-resourced vs. 6.2% high-resourced clinics (p<0.001). The mean (standard deviation [SD]) age of depressed CHD patients was 66.5 (11.6); 64.2% were female, 72.8% Hispanic, 16.8% Black. Over the last 2 years, depression screen positive rates remained unchanged but depressed CHD patients demonstrated lower patient activation (39.1 vs. 34.9, p=0.050) and interest in therapy/cardiac rehab but greater interest in antidepressants (p<0.001). Mean (SD) days exercising were overall low (1.3 [2.0]). Social/system-level factors were not associated with behavioral risk factors of recurrent cardiovascular disease. Conclusion: Over the last 2 years, patient activation, a key predictor of cardiovascular risk, worsened among depressed CHD patients. While social/system-level factors (i.e., lack of quality care) may contribute to depression burden, once depressed, CHD patients demonstrate suboptimal preventative behaviors, like physical activity, engagement/activation, and depression treatment-seeking, regardless of system-level resources. Future research should elucidate reasons for waning interest in cardiac rehab and therapy in this high-risk population, and consider activation interventions that meet patients in their communities or homes.

Background: Few if any examples exist of how best to select and adapt sustainability strategies. We used a collaborative/integrated care use case to describe a novel, theory-informed, stakeholder engaged process for operationalizing sustainability strategies. Methods: Informed by the Behavior Change Wheel, we used mixed methods to identify key sustainability behaviors and determinants of sustainability before conducting a “sustainability mapping” phase to identify acceptable and equitable intervention functions and behavioral change techniques. Drawing on user centered design principles, we enlisted 22 national and local stakeholders to operationalize and adapt (e.g., content, functionality, workflow) a multi-level sustainability strategy to maximally target behavioral determinants of sustainability. Results: We identified ongoing provider treatment optimization and patient initiation as key sustainability behaviors in settings receiving external facilitation and fiscal implementation strategies. The most acceptable, equitable and feasible intervention functions included environmental restructuring, education, training, modeling, persuasion, and enablement. We determined that a waiting room delivered shared decision making and psychoeducation patient tool (DepCare) the results of which are delivered to providers as well as ongoing problem-solving/implementation team meetings with care managers would be the most acceptable and equitable multi-level strategy in diverse settings seeking to sustain CC programs. Key adaptations in response to contextual factors included expanding the DepCare tool to incorporate anxiety/suicide screening, triage support, multi-modal delivery, and patient activation (vs. shared decision making); pairing preference reports with decisional support as well as yearly onboarding/motivational provider and staff educational videos; shifting problem solving meetings from billing support to triage/reducing inappropriate referrals. Conclusion: We provide a roadmap for designing theory-informed, sustainability strategies and employing user centered design principles to adapt strategies to changing mental health landscapes.