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

对退伍军人医疗保健的预期影响：这项研究将告知提供者和系统级 干预措施，以优化创伤后循证心理治疗（EBP）的有效性 常规临床实践中的应激障碍（PTSD）。 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 可以使用EBPs。这些努力主要集中在PTSD的两个EBP-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VHA CPT或PE能力培训。提供CPT和PE的治疗师必须使用 模板化CPT和PE图表注释，用于会议文档，提供有关规定的详细信息 CPT和PE的元素在每个会话中交付。以前对CPT和PE的研究主要集中在 治疗结果、提供者的接受情况以及患者退出的原因。被低估的是 治疗师在其有效性、CPT和PE质量指标方面的系统差异 交付，以及有利于积极成果的工作条件。通过解决这些证据缺口，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 改善创伤后应激障碍退伍军人的治疗保留和临床结果。 项目目标：具体目标是：（a）检查CPT治疗师之间的系统差异， PE结局，以及某些治疗师是否对脆弱患者亚组更有效，以及（B） 确定治疗关系和治疗师依从性是否预测CPT和PE结局， 这些治疗质量指标是否可以解释治疗师在患者中的系统差异 成果。探索性的目的是：（a）确定是否强度和时间之间的一致性， 会话有助于患者的结果，并至少部分地解释了系统性差异， （B）检查治疗师的病例量、诊所环境和资源是否 在治疗师的工作环境中进行治疗有助于患者的结果，并且至少部分地解释了 治疗师在患者结果方面的系统差异;以及（c）阐明以下方面的定量结果： 治疗效果、治疗质量和与患者结局相关的治疗师工作背景方面 通过定性访谈。 项目方法：这是一项对200名提供CPT或CPT治疗的治疗师进行的解释性序贯混合方法研究。 约2,000名PTSD患者的PE。如果治疗师使用图表注释模板，则将招募他们 VHA要求记录CPT和PE，并在一年内治疗至少3例CPT或PE患者。 这些治疗师的患者将被纳入，如果他们有创伤后应激障碍的诊断，并接受至少两次会议 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， 确保高质量的CPT和PE文档，并进行调查，以评估培训历史和资源， EBP在工作环境中PTSD的患者保留治疗和临床改善是治疗的关键。 主要成果。为了划分患者和治疗师水平之间患者结果的总方差，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， 并辅以调查数据。定性访谈的目的性样本32治疗师后， 定量数据收集将说明定量结果的背景、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