Optimizing treatment response in VA Specialized Intensive/Inpatient PTSD programs

背景：创伤后应激障碍（PTSD）影响着大约23%的退伍军人， 造成了巨大的心理、身体和经济负担。虽然大多数患有PTSD的退伍军人 在门诊治疗的基础上，VA有39个专门的强化/住院PTSD项目（SIPPs） 旨在治疗需要更密集和密切监测护理的高需求退伍军人。治疗 的患者参加SIPPs是非常昂贵的;只有1%的VA患者与PTSD诊断参加SIPPs 但他们占退伍军人事务部专门创伤后应激障碍治疗预算的33%。此外，尽管有这些成本，许多 接受SIPPs治疗的患者可能仅经历PTSD症状的适度改善。因此，在本发明中， 医学研究所最近呼吁制定策略来改善VA PTSD的治疗结果 治疗一般和具体的住宅计划，明确VA需要仔细评估， 解决接受住院和其他创伤后应激障碍治疗的退伍军人中治疗反应不佳的问题。 目的：本CDA的目的是通过识别个人和项目水平的因素来优化PTSD护理 与住宅项目中的不良治疗反应相关，这将大大提高VA的能力， 为这些高需求、高费用个人提供有针对性的和改进的治疗方法。目标1将确定 在全国范围内的住宅项目中，个人和项目水平的治疗反应预测因子。目标2将 进一步阐明与PTSD治疗反应不良相关的因素，使用定性方法， 患者，提供者和管理人员在VISN 10计划和全国范围内的3个高性能和3个 低绩效计划（基于平均症状变化和14年内再次入院患者的百分比） 出院日）。目标3将试行对现有治疗或卫生服务干预措施进行调整， 根据初步研究目标的结果、高绩效地点的治疗实践数据以及 由导师团队、业务伙伴和前线员工组成的专家小组评估可行性。 方法：本研究以资源、生活事件和心理变化理论为指导， States.目的1将使用全国临床试验的多水平模型评估反应不良的预测因素。 东北计划评估中心收集的信息。感兴趣的变量将包括个人- 水平资源和因素，如合并症、社会背景资源（如低社会支持），以及 计划资源，如循证治疗的可用性。目标2将利用定性分析 通过访谈患者和提供者来评估个人和项目水平的反应预测因素的方法。 目标3将包括在VISN 10创伤后应激障碍住院计划中对60名患者进行可行性试点。 候选人：PI的长期目标是成为独立的VA健康服务调查员， 开发和评估项目，以改善严重和难以治疗的PTSD患者的预后 提高创伤后应激障碍的治疗质量。在此CDA期间，PI将为研究计划奠定基础 重点关注创伤后应激障碍治疗反应不佳，同时建立卫生服务方法的专业知识。PI将 完成以下方面的培训活动：（1）多层次建模，项目评估和其他卫生服务方法， (2)（3）实施科学与成本分析。拟议研究 培训活动将为PI提供技能，以改善退伍军人的PTSD护理。 环境：PI将受益于支持培训和研究的丰富资源 可通过VA HSR&D创新中心，密歇根大学精神病学系， 医疗保健政策与创新研究所和公共卫生学院。她将充分利用 这些机会和支持和协调的导师团队，以丰富她目前和建议 research.拟议的CDA研究非常重要，并涉及关键的VA和ORD优先领域 包括心理健康服务研究和创伤后应激障碍的护理点研究。

Background: Posttraumatic Stress Disorder (PTSD) affects approximately 23% of returning Veterans and produces significant psychological, physical, and economic burdens. Although most Veterans with PTSD are treated on an outpatient basis, the VA has 39 Specialized Intensive/Inpatient PTSD programs (SIPPs) designed to treat high-needs Veterans who require more intensive and closely monitored care. The treatment of patients enrolled in SIPPs is extremely costly; only 1% of VA patients with a PTSD diagnosis enroll in SIPPs but they account for 33% of VA's budget for specialized PTSD care. Furthermore, despite these costs, many patients undergoing treatment in SIPPs may experience only modest improvements in PTSD symptoms. Thus, the Institute of Medicine has recently called for strategies to improve treatment outcomes of VA PTSD treatment in general and residential programs specifically, making it clear the VA needs to carefully assess and address poor treatment response among Veterans receiving residential and other PTSD treatment. Objectives: The goal of this CDA is to optimize PTSD care by identifying individual- and program-level factors associated with poor treatment response in residential programs, which will greatly enhance the VA's ability to target and improve treatment approaches for these high-need, high-cost individuals. Aim 1 will identify individual- and program-level predictors of treatment response in residential programs nationwide. Aim 2 will further elucidate factors associated with poor PTSD treatment response, using a qualitative approach with patient, provider, and administrator interviews at a VISN 10 program and nationally at 3 high-performing and 3 low-performing programs (based on average symptom change and percent of patients readmitted within 14 days of discharge). Aim 3 will pilot an adaptation of an existing treatment or health services intervention based on findings from the initial study aims, data on treatment practices at high-performing sites, and assessment of feasibility from an expert panel consisting of the mentorship team, operational partners, and frontline staff. Methods: This research will be guided by the theory of Resources, Life Events and Changes in Psychological States. Aim 1 will assess predictors of poor response using multilevel modeling of nationwide clinical information collected by the Northeast Program Evaluation Center. Variables of interest will include individual- level resources and factors such as comorbidities, social contextual resources (e.g. low social support), and program resources such the availability of evidence-based treatments. Aim 2 will utilize qualitative analytic methods to assess individual and program-level predictors of response by interviewing patients and providers. Aim 3 will consist of a feasibility pilot conducted with 60 patients at a VISN 10 residential program for PTSD. Candidate: The PI's long-term goal is to become an independent VA health services investigator who develops and evaluates programs to improve outcomes for individuals with severe and difficult-to-treat PTSD and improve care quality for PTSD. During this CDA, the PI will build the foundation of a research program focusing on poor PTSD treatment response while building expertise in health services methods. The PI will complete training activities in: (1) multilevel modeling, program evaluation, and other health services methods, (2) qualitative and mixed methods, and (3) Implementation Science and cost analysis. The proposed research and training activities will provide the PI with the skills to inform improved PTSD care for Veterans. Environment: The PI will benefit from the wealth of resources supporting training and research that are available through the VA HSR&D Center of Innovation, the University of Michigan Department of Psychiatry, the Institute for Healthcare Policy and Innovation, and the School of Public Health. She will make full use of these opportunities and the supportive and coordinated mentorship team to enrich her current and proposed research. The proposed CDA research is highly significant and addresses key VA and ORD priority areas including mental health services research and advancing Point of Care Research in PTSD.