Texas Health Resources Foundation

IMPORTANCE: The effect of surgical complications on hospital finances is unclear. OBJECTIVE: To determine the relationship between major surgical complications and per-encounter hospital costs and revenues by payer type. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of administrative data for all inpatient surgical discharges during 2010 from a nonprofit 12-hospital system in the southern United States. Discharges were categorized by principal procedure and occurrence of 1 or more postsurgical complications, using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes. Nine common surgical procedures and 10 major complications across 4 payer types were analyzed. Hospital costs and revenue at discharge were obtained from hospital accounting systems and classified by payer type. MAIN OUTCOMES AND MEASURES: Hospital costs, revenues, and contribution margin (defined as revenue minus variable expenses) were compared for patients with and without surgical complications according to payer type. RESULTS: Of 34,256 surgical discharges, 1820 patients (5.3%; 95% CI, 4.4%-6.4%) experienced 1 or more postsurgical complications. Compared with absence of complications, complications were associated with a $39,017 (95% CI, $20,069-$50,394; P < .001) higher contribution margin per patient with private insurance ($55,953 vs $16,936) and a $1749 (95% CI, $976-$3287; P < .001) higher contribution margin per patient with Medicare ($3629 vs $1880). For this hospital system in which private insurers covered 40% of patients (13,544), Medicare covered 45% (15,406), Medicaid covered 4% (1336), and self-payment covered 6% (2202), occurrence of complications was associated with an $8084 (95% CI, $4903-$9740; P < .001) higher contribution margin per patient ($15,726 vs $7642) and with a $7435 lower per-patient total margin (95% CI, $5103-$10,507; P < .001) ($1013 vs -$6422). CONCLUSIONS AND RELEVANCE: In this hospital system, the occurrence of postsurgical complications was associated with a higher per-encounter hospital contribution margin for patients covered by Medicare and private insurance but a lower one for patients covered by Medicaid and who self-paid. Depending on payer mix, many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

BACKGROUND: There is increasing interest in using prediction models to identify patients at risk of readmission or death after hospital discharge, but existing models have significant limitations. Electronic medical record (EMR) based models that can be used to predict risk on multiple disease conditions among a wide range of patient demographics early in the hospitalization are needed. The objective of this study was to evaluate the degree to which EMR-based risk models for 30-day readmission or mortality accurately identify high risk patients and to compare these models with published claims-based models. METHODS: Data were analyzed from all consecutive adult patients admitted to internal medicine services at 7 large hospitals belonging to 3 health systems in Dallas/Fort Worth between November 2009 and October 2010 and split randomly into derivation and validation cohorts. Performance of the model was evaluated against the Canadian LACE mortality or readmission model and the Centers for Medicare and Medicaid Services (CMS) Hospital Wide Readmission model. RESULTS: Among the 39,604 adults hospitalized for a broad range of medical reasons, 2.8% of patients died, 12.7% were readmitted, and 14.7% were readmitted or died within 30 days after discharge. The electronic multicondition models for the composite outcome of 30-day mortality or readmission had good discrimination using data available within 24 h of admission (C statistic 0.69; 95% CI, 0.68-0.70), or at discharge (0.71; 95% CI, 0.70-0.72), and were significantly better than the LACE model (0.65; 95% CI, 0.64-0.66; P =0.02) with significant NRI (0.16) and IDI (0.039, 95% CI, 0.035-0.044). The electronic multicondition model for 30-day readmission alone had good discrimination using data available within 24 h of admission (C statistic 0.66; 95% CI, 0.65-0.67) or at discharge (0.68; 95% CI, 0.67-0.69), and performed significantly better than the CMS model (0.61; 95% CI, 0.59-0.62; P < 0.01) with significant NRI (0.20) and IDI (0.037, 95% CI, 0.033-0.041). CONCLUSIONS: A new electronic multicondition model based on information derived from the EMR predicted mortality and readmission at 30 days, and was superior to previously published claims-based models.

Communication problems in healthcare are considered to be a leading cause of medical errors and often the root cause of sentinel events. This article will review the implementation of TeamSTEPPS in the two large health systems. The challenges in the implementation process, the successes, failures, and the obstacles will be discussed. Comparisons between the systems as well as lessons learned after implementation will be reviewed to enable hospitals and health systems to implement and sustain a successful TeamSTEPPS program.

BACKGROUND: Incorporating clinical information from the full hospital course may improve prediction of 30-day readmissions. OBJECTIVE: To develop an all-cause readmissions risk-prediction model incorporating electronic health record (EHR) data from the full hospital stay, and to compare "full-stay" model performance to a "first day" and 2 other validated models, LACE (includes Length of stay, Acute [nonelective] admission status, Charlson Comorbidity Index, and Emergency department visits in the past year), and HOSPITAL (includes Hemoglobin at discharge, discharge from Oncology service, Sodium level at discharge, Procedure during index hospitalization, Index hospitalization Type [nonelective], number of Admissions in the past year, and Length of stay). DESIGN: Observational cohort study. SUBJECTS: All medicine discharges between November 2009 and October 2010 from 6 hospitals in North Texas, including safety net, teaching, and nonteaching sites. MEASURES: Thirty-day nonelective readmissions were ascertained from 75 regional hospitals. RESULTS: Among 32,922 admissions (validation = 16,430), 12.7% were readmitted. In addition to many first-day factors, we identified hospital-acquired Clostridium difficile infection (adjusted odds ratio [AOR]: 2.03, 95% confidence interval [CI]: 1.18-3.48), vital sign instability on discharge (AOR: 1.25, 95% CI: 1.15-1.36), hyponatremia on discharge (AOR: 1.34, 95% CI: 1.18-1.51), and length of stay (AOR: 1.06, 95% CI: 1.04-1.07) as significant predictors. The full-stay model had better discrimination than other models though the improvement was modest (C statistic 0.69 vs 0.64-0.67). It was also modestly better in identifying patients at highest risk for readmission (likelihood ratio +2.4 vs. 1.8-2.1) and in reclassifying individuals (net reclassification index 0.02-0.06). CONCLUSIONS: Incorporating clinically granular EHR data from the full hospital stay modestly improves prediction of 30-day readmissions. Given limited improvement in prediction despite incorporation of data on hospital complications, clinical instabilities, and trajectory, our findings suggest that many factors influencing readmissions remain unaccounted for. Further improvements in readmission models will likely require accounting for psychosocial and behavioral factors not currently captured by EHRs. Journal of Hospital Medicine 2016;11:473-480. © 2016 Society of Hospital Medicine.

BACKGROUND: Empirical evidence supports the contention that implementing caring nurse behaviors results in improved patient experience; however, previous studies find differences between patient and nurse perceptions of caring. SIGNIFICANCE: Good patient experience is positively related to desired clinical and financial outcomes. Nurse caring is a critical component in the patient experience. OBJECTIVE: The purposes of this project were to evaluate the congruency between nurse and patient perceptions of nurse caring in a long-term acute care hospital and to determine how much patient perception of nurse caring changes over time. METHOD: The study employed mixed methods using a triangulation strategy in which quantitative data from patients and qualitative data from nurses were collected simultaneously and compared for interpretation. RESULTS: Time affected patient perception of caring significantly. Patients and nurses disagreed about the extent to which nurses ask patients what they know about their illnesses, help them deal with bad feelings, and make them feel comfortable. CONCLUSION: Patients and nurses do not always agree about the quality of caring behaviors, but exposure to nurses over time positively affects patient perception of nurse caring.

The results of hemiarthroplasty as treatment for comminuted humerus fractures are poor in elderly patients. While hemiarthroplasty is also an unreliable treatment for rotator cuff tear arthropathy, reverse shoulder arthroplasty (RSA) has been a reliable salvage procedure. The present study examines the result of RSA as treatment for comminuted proximal humeral fractures in elderly patients. Thirteen elderly patients underwent RSA for comminuted proximal humeral fractures. Follow-up ranged from 8 months to 46 months. Patients were assessed retrospectively for Constant-Murley score, rate of complications, and postoperative radiographic review, and data were compared to historical controls. Mean Constant-Murley score was 67 points (range, 45-77 points). No dislocations occurred. Two patients sustained a postinjury auxiliary nerve palsy, one of which resolved only partially. One patient sustained a postinjury radial nerve palsy that resolved. One patient underwent evacuation of a postoperative wound hematoma. No shoulder needed revision. RSA should be considered a salvage procedure, whether performed for cuff tear arthropathy or severe proximal humerus fracture. Even so, RSA can provide immediate shoulder stability for elderly patients with severe shoulder injuries, and results compare favorably to historical controls for hemiarthroplasty in these patients.

Patient-controlled analgesia (PCA) is a widely used delivery system for intravenous (IV) administration of opioids during acute post-operative pain management. Various opioids have been used for IV PCA including morphine, meperidine, hydromorphone, and fentanyl. Morphine is by far the most commonly used opioid in this setting, yet the selection of morphine as the primary opioid is based largely on tradition. Meperidine should not be considered in the PCA armamentarium due to the associated risk of central nervous system toxicity from its metabolite normeperidine. The objective of this study is to compare the rate of opioid-induced adverse reactions among three IV PCA opioids, fentanyl, morphine, and hydromorphone, in acute post-operative pain management. Although morphine is the most frequently used opioid, the results from three US hospitals indicate that fentanyl IV PCA had a significantly lower rate of common opioid induce adverse reactions (nausea/vomiting, pruritus, urinary retention, or sedation), when compared to IV PCA morphine and hydromorphone in acute post-operative pain management. The median pain score on post-operative day-1 and -2 was significantly lower in fentanyl IV PCA group. The quantity of opioid in each group was not significantly different when converted to an analgesic equivalence. Morphine and hydromorphone IV PCA were no different in rates of adverse reactions in any area; although, the hydromorphone group trended toward a lower pruritus and urinary retention rate compared to morphine, but this was not statistically significant. The rate of respiratory depression was not significantly different between the three opioids. Fentanyl IV PCA is an under used opioid for post-operative acute-pain management and should be considered more often due to the lower adverse reaction profile.

BACKGROUND: Defining clinical conditions from electronic health record (EHR) data underpins population health activities, clinical decision support, and analytics. In an EHR, defining a condition commonly employs a diagnosis value set or "grouper." For constructing value sets, Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) offers high clinical fidelity, a hierarchical ontology, and wide implementation in EHRs as the standard interoperability vocabulary for problems. OBJECTIVE: This article demonstrates a practical approach to defining conditions with combinations of SNOMED CT concept hierarchies, and evaluates sharing of definitions for clinical and analytic uses. METHODS: We constructed diagnosis value sets for EHR patient registries using SNOMED CT concept hierarchies combined with Boolean logic, and shared them for clinical decision support, reporting, and analytic purposes. RESULTS: A total of 125 condition-defining "standard" SNOMED CT diagnosis value sets were created within our EHR. The median number of SNOMED CT concept hierarchies needed was only 2 (25th-75th percentiles: 1-5). Each value set, when compiled as an EHR diagnosis grouper, was associated with a median of 22 International Classification of Diseases (ICD)-9 and ICD-10 codes (25th-75th percentiles: 8-85) and yielded a median of 155 clinical terms available for selection by clinicians in the EHR (25th-75th percentiles: 63-976). Sharing of standard groupers for population health, clinical decision support, and analytic uses was high, including 57 patient registries (with 362 uses of standard groupers), 132 clinical decision support records, 190 rules, 124 EHR reports, 125 diagnosis dimension slicers for self-service analytics, and 111 clinical quality measure calculations. Identical SNOMED CT definitions were created in an EHR-agnostic tool enabling application across disparate organizations and EHRs. CONCLUSION: SNOMED CT-based diagnosis value sets are simple to develop, concise, understandable to clinicians, useful in the EHR and for analytics, and shareable. Developing curated SNOMED CT hierarchy-based condition definitions for public use could accelerate cross-organizational population health efforts, "smarter" EHR feature configuration, and clinical-translational research employing EHR-derived data.

OBJECTIVES: Growing evidence supports the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle processes as improving a number of short- and long-term clinical outcomes for patients requiring ICU care. To assess the cost-effectiveness of this intervention, we determined the impact of ABCDE bundle adherence on inpatient and 1-year mortality, quality-adjusted life-years, length of stay, and costs of care. DESIGN: We conducted a 2-year, prospective, cost-effectiveness study in 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system. SETTING: Hospitals included a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units. PATIENTS: The study included 2,953 patients, 18 years old or older, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days. INTERVENTION: ABCDE bundle. MEASUREMENTS AND MAIN RESULTS: We used propensity score-adjusted regression models to determine the impact of high bundle adherence on inpatient mortality, discharge status, length of stay, and costs. A Markov model was used to estimate the potential effect of improved bundle adherence on healthcare costs and quality-adjusted life-years in the year following ICU admission. We found that patients with high ABCDE bundle adherence (≥ 60%) had significantly decreased odds of inpatient mortality (odds ratio 0.28) and significantly higher costs ($3,920) of inpatient care. The incremental cost-effectiveness ratio of high bundle adherence was $15,077 (95% CI, $13,675-$16,479) per life saved and $1,057 per life-year saved. High bundle adherence was associated with a 0.12 increase in quality-adjusted life-years, a $4,949 increase in 1-year care costs, and an incremental cost-effectiveness ratio of $42,120 per quality-adjusted life-year. CONCLUSIONS: The ABCDE bundle appears to be a cost-effective means to reduce in-hospital and 1-year mortality for patients with an ICU stay.

This article examines the relationship between progress toward the Community Care Network (CCN) vision and "intermediate outcomes" of 25 community-based health partnerships (CCNs). Specific components of the CCN vision were community accountability, community health focus, creation of a seamless service continuum, and managing under limited resources. Four community outcome dimensions were evaluated: access, cost, health, and quality of service delivery integration. Overall progress toward the CCN vision was significantly positively related to average intermediate outcome score and most highly correlated with two dimensions: access and quality of service integration. Qualitative analysis suggests that CCN sites accomplished the most along two dimensions--access and health--noting that intermediate health outcomes generally were in health assessment and information rather than actual health status improvement. Keys to outcome achievement appear to be (1) clearly focused intervention; (2) explicit, ongoing outcome measurement; and (3) strong integration of separate intervention components.

Centralized water infrastructure has, over the last century, brought safe and reliable drinking water to much of the world. But climate change, combined with aging and underfunding, is increasingly testing the limits of-and reversing gains made by-these large-scale water systems. To address these growing strains and gaps, we must assess and advance alternatives to centralized water provision and sanitation. The water literature is rife with examples of systems that are neither centralized nor networked, but still meet water needs of local communities in important ways, including: informal and hybrid water systems, decentralized water provision, community-based water management, small drinking water systems, point-of-use treatment, small-scale water vendors, and packaged water. Our work builds on these literatures by proposing a convergence approach that can integrate and explore the benefits and challenges of modular, adaptive, and decentralized ("MAD") water provision and sanitation, often foregrounding important advances in engineering technology. We further provide frameworks to evaluate justice, economic feasibility, governance, human health, and environmental sustainability as key parameters of MAD water system performance.

PURPOSE: To determine whether mothers of newborns understand basic facts about newborn screening (NBS), and how they feel about state retention of dried bloodspots (DBS) for research use. DESIGN: This study was a cross-sectional survey administered to 548 mothers of newborns in postpartum units in five different hospitals in north Texas after Institutional Review Board approval. Each participating site delivered and collected surveys using systems that were convenient for them. The survey instrument used in this study is the Maternal Attitudes and Knowledge about Newborn Screening Survey. The survey was developed by the investigators. Summary statistics were provided for each participating site and surveys were combined for final data analysis. Multiple regression analysis was used to quantify associations between responses and demographic variables. RESULTS: Overall, knowledge about details of NBS and DBS retention was inadequate. The most frequent source of information about NBS was the postpartum nurse. Mothers tended to believe that using newborn bloodspots for research was a good thing, but Medicaid recipients and minorities were more reluctant than others to share dried bloodspots for research. CLINICAL IMPLICATIONS: Mothers are not fully informed about NBS or the use of infant bloodspots for research. Bloodspot storage in Texas could shrink under new opt-in policies, constraining a resource needed for genetic and other research. Further research to design and test educational interventions that are sensitive to the concerns of parents about DBS storage and that can be efficiently implemented antenatally is needed.

Purpose To report comparative hip arthroscopic outcomes of patients with low (borderline dysplasia), normal, and high (global pincer femoroacetabular impingement [FAI]) lateral acetabular coverage. Methods A retrospective analysis of prospectively collected data from a multicenter registry was performed. Primary hip arthroscopy patients were assigned to 1 of 3 groups based on preoperative lateral center‐edge angle: borderline dysplasia (≤25°), normal (25.1°‐38.9°), and pincer (≥39°). Repeated‐measures analysis of variance compared preoperative with 2‐year minimum postoperative International Hip Outcome Tool (iHOT‐12) scores. Subsequent analysis of variance determined the effect of acetabular coverage on magnitude of change in scores. Results Of 437 patients, the only statistical difference between groups was a lower prevalence of acetabuloplasty in the borderline dysplasia group ( P = .001). A significant improvement in the preoperative to postoperative iHOT‐12 scores for patients with normal acetabular coverage, acetabular undercoverage, and acetabular overcoverage was observed: F(1, 339) = 311.06; P &lt; . 001, with no statistical differences in preoperative ( P = .505) and postoperative ( P &lt; . 488) iHOT‐12 scores when comparing the groups based on acetabular coverage. Mean iHOT‐12 scores increased from 37.3 preoperatively to 68.7 postoperatively ( P &lt; . 001) in the borderline dysplasia group, from 34.4 to 72 ( P &lt; . 001) in the normal coverage group, and from 35.3 to 69.4 ( P &lt; . 001) in the pincer group. These preoperative scores increased by 31.4, 37.8, and 34.1, respectively, with no effect for acetabular coverage on the magnitude of change from preoperative to postoperative iHOT‐12 scores: F(2,339) = 1.18; P = .310. Ten patients (2.3%) underwent conversion arthroplasty, and 19 patients (4.4%) underwent revision arthroscopy with no significant effect of acetabular coverage on the incidence of revision or conversion surgery: χ 2 (6,433) = 11.535; P = .073. Conclusions Lateral acetabular coverage did not influence outcomes from primary hip arthroscopy when performed in patients with low (borderline dysplasia), normal, and high (global pincer FAI) lateral center‐edge angle. Borderline dysplasia and moderate global pincer FAI with no or minimal osteoarthritis do not compromise successful 2‐year minimum outcomes or survivorship following primary hip arthroscopy when performed by experienced surgeons. Level of Evidence Level III, retrospective therapeutic trial.

Research has shown that preoperative fasting practices commonly are much longer than national guidelines, and medication instructions are not always given to patients before surgery. After implementation of an evidence-based preoperative fasting policy and educational efforts for health care providers at one facility, a follow up project was conducted to determine whether these efforts had improved fasting practices. The project findings indicate that preoperative fasting in excess of safe minimum guidelines persists. Improvements were found in the percentage of patients receiving specific instructions about whether to take their routine medications on the morning of surgery. Continued efforts must be made to implement best practices for preoperative fasting.

Objectives: The objective of this study was to determine if there was a significant difference between the sleep quality of patients who inhaled placebo and those who inhaled an aroma comprising a mixture of Lavandula x intermedia (Lavandin Super), Citrus bergamia (bergamot), and Cananga odorata (ylang ylang). Design: This was a randomized, double-blind crossover study, which compared a treatment with placebo. Settings/location: The study was conducted in an outpatient cardiac rehabilitation unit located in an urban, private nonprofit hospital in north Texas. Subjects: Participants included 42 adult patients referred to the rehabilitation service following hospitalizations by local cardiologists. Interventions: Cotton balls infused with a combination of lavender, bergamot, and ylang ylang or placebo were placed at subjects' bedsides for five nights. After a washout period, subjects crossed over to the other condition for five nights. Outcome measures: Participants completed the Pittsburgh Sleep Quality Index (PSQI) after treatment and placebo periods. Lower PSQI scores indicate better sleep quality. Results: The mean PSQI global score was statistically significantly lower when receiving the intervention oil (mean = 4.9) than the mean PSQI global score when receiving placebo (mean = 8). Duration of sleep and the time it took to fall asleep were no different between treatment groups, but patient-reported sleep quality was significantly better when participants were exposed to essential oils (χ2 = 4.5, p = 0.03) than when exposed to placebo. Although sleep efficiency (time asleep while lying in bed) was perceived as the same under both conditions, participants reported that they had to get up to use the bathroom significantly less often when exposed to the treatment than when exposed to placebo (t = −2.04, p = 0.05; Wilcoxon p = 0.05). Participants also reported that they had trouble sleeping because they felt too cold, which occurred significantly less often when exposed to the treatment than when exposed to placebo (t = −2.03, p = 0.05; Wilcoxon p = 0.05). Conclusions: Sleep quality of participants receiving intervention oils was significantly better than the sleep quality of participants receiving the placebo oil. Low-cost, nontraditional aromatherapy treatment is potentially effective for improving sleep quality among cardiac rehabilitation patients.

OBJECTIVE: We sought to demonstrate applicability of user stories, progressively elaborated by testable acceptance criteria, as lightweight requirements for agile development of clinical decision support (CDS). MATERIALS AND METHODS: User stories employed the template: As a [type of user], I want [some goal] so that [some reason]. From the "so that" section, CDS benefit measures were derived. Detailed acceptance criteria were elaborated through ensuing conversations. We estimated user story size with "story points," and depicted multiple user stories with a use case diagram or feature breakdown structure. Large user stories were split to fit into 2-week iterations. RESULTS: One example user story was: As a rheumatologist, I want to be advised if my patient with rheumatoid arthritis is not on a disease-modifying anti-rheumatic drug (DMARD), so that they receive optimal therapy and can experience symptom improvement. This yielded a process measure (DMARD use), and an outcome measure (Clinical Disease Activity Index). Following implementation, the DMARD nonuse rate decreased from 3.7% to 1.4%. Patients with a high Clinical Disease Activity Index improved from 13.7% to 7%. For a thromboembolism prevention CDS project, diagrams organized multiple user stories. DISCUSSION: User stories written in the clinician's voice aid CDS governance and lead naturally to measures of CDS effectiveness. Estimation of relative story size helps plan CDS delivery dates. User stories prove to be practical even on larger projects. CONCLUSIONS: User stories concisely communicate the who, what, and why of a CDS request, and serve as lightweight requirements for agile development to meet the demand for increasingly diverse CDS.

The presence of per- and polyfluoroalkyl substances (PFAS) in U.S. drinking water has recently garnered significant attention from the media, federal government, and public health professionals. While concerns for PFAS exposure continue to mount, the general public's awareness and knowledge of the contaminant has remained unknown. This exploratory study sought to fill this data gap by administering a nationwide survey in which the awareness of PFAS and community contamination, awareness of PFAS containing products and intentions to change product use, and awareness and concern about PFAS in drinking water were assessed. The results indicated that almost half the respondents had never heard of PFAS and do not know what it is (45.1%). Additionally, 31.6% responded that they had heard of PFAS but do not know what it is. A large portion of respondents (97.4%) also responded that they did not believe their drinking water had been impacted by PFAS. Demographic association did not influence knowledge of PFAS or levels of concern with PFAS in drinking water. The strongest predictor of PFAS awareness was awareness due to known community exposure. The respondents aware of community exposure were more likely to have knowledge of PFAS sources, change their use of items with potential PFAS contamination, and answer that their drinking water sources were also contaminated with PFAS. Based on the received responses, PFAS information and health risks need to be better communicated to the public to help increase awareness. These efforts should also be coordinated between government agencies, utilities, the research community, and other responsible entities to bolster their effectiveness.

The main purpose of this study was to evaluate participant engagement and effects of an Internet-based, self-directed program for depressive symptoms piloted among adults with a chronic disease. Eligible participants ( N = 47) were randomly assigned to either the "Think Clearly About Depression" online depression self-management program or the control group. The Patient Health Questionnaire-8 and Chronic Disease Self-Efficacy Scales were administered at baseline and at Weeks 4 and 8 after initiating the intervention. Number Needed to Treat analysis indicated that one in every three treatment group participants found clinically significant reductions in depressive symptoms by Week 8. Paired-sample t tests showed that depressive symptoms and self-efficacy in management of depressive symptoms improved over time for those in the treatment group and not for those in the control group. Participants' engagement and satisfaction with the online program were favorable.