Shared Contributions to Outcomes and Retention in EBPs for PTSD (SCORE PTSD)

对退伍军人医疗的预期影响：这项研究将向提供者和系统层面提供信息 优化创伤后循证心理治疗(EBPS)有效性的干预措施 应激障碍(PTSD)在常规临床实践中。 项目背景：VHA已投入大量资源，以确保所有患有创伤后应激障碍的退伍军人 有权获得EBPS。这些努力主要集中在两个用于创伤后应激障碍的EBPS-认知加工 治疗(CPT)和长期暴露(PE)。在过去的十年中，超过6,300名VHA临床医生 接受过基于VHA能力的CPT或体育培训。提供CPT和PE的治疗师必须使用 会议文件的CPT和PE图表备注模板，提供有关规定的详细信息 在每次课程中提供CPT和PE的要素。以往对CPT和PE的研究主要集中在 治疗结果、提供者的吸收情况以及患者中途退出的原因。未被研究的有 治疗师在治疗效果、CPT和PE质量指标上的系统差异 以及有利于取得积极成果的工作条件。通过解决这些证据差距，我们将 确定影响CPT和PE交付的可修改因素，我们可以针对这些因素进行干预，从而 改善患有创伤后应激障碍的退伍军人的治疗保留率和临床结果。 项目目标：具体目标是：(A)检查CPT和CPT中治疗师之间的系统差异 PE的结果，以及某些治疗师是否对脆弱的患者亚群更有效，以及(B) 确定治疗关系和治疗师的依从性是否可以预测CPT和PE的结果 这些治疗质量指标是否解释了患者治疗师之间的系统性差异 结果。探索性目标是：(A)确定时间的强度和一致性 疗程有助于患者的预后，并至少部分解释了 治疗师对患者结果的影响；(B)审查治疗师的工作量、临床环境和资源 在治疗师的工作环境中提供治疗有助于患者的结果，并至少部分解释了 治疗师之间在患者结果上的系统差异；以及(C)阐明关于 治疗师的效果、治疗质量和与患者结果相关的治疗师工作环境方面 通过定性访谈。 项目方法：这是一项解释性序贯混合方法研究，对象为200名提供CPT或 向大约2,000名创伤后应激障碍患者进行体育锻炼。如果治疗师使用图表注释模板，他们将被登记 VHA要求提供CPT和PE的记录，并在一年内至少治疗三名CPT或PE患者。 这些治疗师的患者如果被诊断为创伤后应激障碍并接受至少两次治疗，将被包括在内 CPT或PE。注册后，治疗师将完成简短的在线CPT和PE模板复习教程，以 确保高质量的CPT和PE文档以及评估培训历史和资源的调查 在他们的工作环境中的EBP。患者在治疗中的保留和临床上的改善是创伤后应激障碍 主要结果。为了在患者和治疗师水平之间划分患者结果的总差异，我们 将使用来自VHA管理数据集和图表注释的治疗师和患者数据的多级建模， 辅以调查数据。对32名治疗师进行了有目的的定性访谈 量化数据收集将对量化结果进行背景分析、解释和说明。 1

Anticipated Impacts on Veterans Healthcare: This research will inform provider- and system-level interventions to optimize the effectiveness of evidence-based psychotherapies (EBPs) for Posttraumatic Stress Disorder (PTSD) in routine clinical practice. Project Background: VHA has committed considerable resources to ensuring that all veterans with PTSD have access to EBPs. These efforts have focused primarily on two EBPs for PTSD – Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). Over the past decade more than 6,300 VHA clinicians have received VHA competency based training in CPT or PE. Therapists providing CPT and PE are required to use templated CPT and PE chart notes for session documentation, providing detailed information on the prescribed elements of CPT and PE delivered in each session. Prior research on CPT and PE has focused primarily on treatment outcomes, uptake among providers and reasons for drop-out among patients. Understudied are systematic differences between therapists in their effectiveness, indicators of the quality of CPT and PE delivery, and the work conditions conducive to positive outcomes. By addressing these evidence-gaps, we will identify modifiable factors affecting CPT and PE delivery that we can target for intervention and thereby improve treatment retention and clinical outcomes among Veterans with PTSD. Project Objectives: Specific aims are to: (a) Examine systematic differences between therapists in CPT and PE outcomes, and whether certain therapists are more effective with vulnerable patient subgroups, and (b) Determine whether the therapeutic relationship and therapist adherence predict CPT and PE outcomes and whether these indicators of therapy quality explain systematic differences between therapists in patient outcomes. Exploratory aims are to: (a) Determine whether the intensity and consistency of time between sessions contribute to patient outcomes and at least partially account for systematic differences between therapists in patient outcomes; (b) Examine whether therapist caseload, clinic setting and resources for therapy delivery in therapists' work environment contribute to patient outcomes and at least partially account for systematic differences between therapists in patient outcomes; and (c) Elucidate quantitative findings on therapist effects, therapy quality and aspects of therapist work context associated with patient outcomes through qualitative interviews. Project Methods: This is an explanatory sequential mixed-method study of 200 therapists who deliver CPT or PE to approximately 2,000 patients with PTSD. Therapists will be enrolled if they use the chart note templates VHA requires for documentation of CPT and PE and treat at least three patients with CPT or PE over one year. Patients of these therapists will be included if they have a diagnosis of PTSD and receive at least two sessions of CPT or PE. After enrollment, therapists will complete a brief online CPT and PE template refresher tutorial to ensure high quality CPT and PE documentation and a survey to assess training history and resources for EBPs in their work environment. Patient retention in treatment and clinical improvement in PTSD are the primary outcomes. To partition the total variance in patient outcomes between patient and therapist levels, we will use multilevel modeling of therapist and patient data from VHA administrative datasets and chart notes, supplemented with survey data. Qualitative interviews with a purposive sample of 32 therapists after quantitative data collection will contextualize, explain and illustrate quantitative findings. 1