Developing a Shared Decision-Making Support Tool to Promote Evidence-based Treatment for Veterans with Post-concussive Sleep Conditions

开发共享决策支持工具，以促进对患有脑震荡后睡眠状况的退伍军人进行循证治疗

• 批准号: 10481936
• 负责人: Adam Kinney
• 金额: --
• 依托单位: VA EASTERN COLORADO HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-07-01 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10481936
• 关键词: Access to Information; Address; Brain; Brain Concussion; Caring; Clinical; Clinical Practice Guideline; Cognition; Collaborations; Computerized Medical Record; Conditioned Insomnia; Data; Decision Aid; Decision Support Systems; Development; Effectiveness; Ensure; Evidence based treatment; Feedback; Fostering; Grant; Guidelines; Healthcare; Intervention; Interview; Investments; Manuals; Methodology; Methods; Military Personnel; Mission; Nature; Obstructive Sleep Apnea; Patient-Centered Care; Patients; Post-Concussion Syndrome; Practice Management; Provider; Quality of Care; Quality of life; Recommendation; Recovery; Recovery of Function; Rehabilitation Centers; Rehabilitation therapy; Research; Risk; Selection for Treatments; Services; Sleep; Sleep Deprivation; Sleep Disorders; Sleep disturbances; Sleeplessness; Specific qualifier value; Structure; Symptoms; System; Training; Veterans; Work; acceptability and feasibility; base; compliance behavior; dashboard; design; disability; evidence base; evidence based guidelines; experience; high risk; implementation strategy; mild traumatic brain injury; mortality; patient response; point of care; preference; prototype; rehabilitative care; routine care; screening; shared decision making; sleep quality; support tools; targeted treatment; tool; treatment center; treatment response; treatment strategy; visual information

Background: Veterans with mild traumatic brain injury (mTBI) are at high risk for sleep conditions (insomnia; obstructive sleep apnea [OSA]), which disrupt sleep quality and undermine recovery. Identifying and treating such sleep conditions using the VA/DoD clinical practice guideline (CPG) for the management of insomnia and OSA (Sleep CPG) can produce wide-ranging benefits for Veterans’ post-concussive recovery. Significance: The Sleep CPG specifies an evidence-based workflow for management of sleep conditions, including: 1) screening for sleep problems; 2) assessing for sleep conditions; and, 3) delivering evidence- based treatments. Further, the Sleep CPG includes a recommendation that Veterans and providers collaborate to select empirically supported treatments to ensure that care aligns with Veterans’ preferences (i.e., Veteran- centered care). However, there exists variability in Veterans’ receipt of guideline-concordant care (GCC) for post-concussive sleep conditions due in part to: 1) lack of access to guideline-recommended practices at the point-of-care (PoC); and, 2) challenges associated with facilitating Veteran-centered care due to the highly individualized nature of Veterans’ preferences. Implementation strategies can enable GCC and facilitate Veterans’ recovery by providing: 1) Veterans and providers with information regarding guideline-recommended practices at the PoC; and, 2) structured support to facilitate Veteran-centered care. However, such strategies have yet to be widely developed or implemented. The proposed project will address this gap in rehabilitative care for those with mTBI and sleep conditions by developing a decision support system. The system will be comprised of two complementary tools. First, it will include a clinical dashboard that distills patient-level data into actionable information at the PoC, providing decision support with respect to: 1) screening for sleep problems; 2) assessments to detect insomnia and/or OSA; and, 3) recommending guideline-concordant treatment options based on clinical presentation. Second, a decision aid will facilitate collaboration between providers and Veterans to promote selection of guideline-concordant treatment recommendations that align with patients’ personal preferences. This will be accomplished by providing Veterans with necessary information and assisting them with clarifying their priorities for intervention. The proposed system will be the first to offer decision support across the continuum of GCC, from screening for sleep problems to Veteran- centered treatment of identified conditions. Specific Aims and Methodology: In Aim 1, we will use semi-structured interviews with Veterans, providers, and policymakers to identify barriers and facilitators to evidence-based, Veteran-centered management of post-concussive sleep conditions. In Aim 2, we will leverage stakeholder input from Aim 1 to develop a decision support system (i.e., dashboard, decision aid) and training materials. We will also use manual chart review to validate the accuracy with which the clinical dashboard provides actionable information to Veterans and providers at the point-of-care. In Aim 3, we will evaluate stakeholder feedback to assess the feasibility and acceptability of the decision support system and associated training materials. After presenting components to stakeholders (e.g., Veterans); we will use a mixed-methods design to elicit feedback and use that feedback to refine the prototype and materials until feasibility and acceptability criteria are met. Deliverables from this proposed project include a feasible, acceptable, and validated support tool capable of ensuring that Veterans with post-concussive sleep conditions receive evidence-based, Veteran- centered care. Findings will enable a subsequent application for a VA RR&D Merit IIR that examines the effectiveness of the decision support system on Veterans’ receipt of quality care and their functional recovery.

背景：患有轻度创伤性脑损伤 (mTBI) 的退伍军人面临睡眠问题（失眠、失眠等）的高风险。 阻塞性睡眠呼吸暂停[OSA]），它会破坏睡眠质量并损害恢复。识别和治疗 使用 VA/DoD 临床实践指南 (CPG) 来管理失眠和睡眠状况 OSA（睡眠 CPG）可以为退伍军人脑震荡后的恢复带来广泛的好处。 意义：睡眠 CPG 指定了用于管理睡眠条件的循证工作流程， 包括：1）筛查睡眠问题； 2) 评估睡眠状况；以及，3）提供证据- 为基础的治疗。此外，睡眠 CPG 还建议退伍军人和提供者合作 选择经验支持的治疗方法，以确保护理符合退伍军人的偏好（即退伍军人 集中护理）。然而，退伍军人接受符合指南的护理 (GCC) 的情况存在差异 脑震荡后睡眠状况的部分原因是：1) 无法获得指南推荐的做法 护理点 (PoC)； 2）由于高度的 退伍军人偏好的个性化本质。实施战略可以使海湾合作委员会发挥作用并促进 通过提供以下方式帮助退伍军人康复： 1) 向退伍军人和提供者提供有关指南推荐的信息 PoC 实践； 2) 结构化支持，以促进以退伍军人为中心的护理。然而，这样的策略 尚未得到广泛开发或实施。拟议的项目将解决康复方面的这一差距 通过开发决策支持系统来护理患有 mTBI 和睡眠状况的患者。该系统将 由两个互补的工具组成。首先，它将包括一个临床仪表板，可提取患者级别的数据 在 PoC 中转化为可操作的信息，提供以下方面的决策支持：1) 睡眠筛查 问题； 2) 检测失眠和/或 OSA 的评估； 3) 推荐符合指南的 根据临床表现选择治疗方案。其次，决策援助将促进双方之间的合作 提供者和退伍军人促进选择符合指南的治疗建议 结合患者个人喜好。这将通过为退伍军人提供必要的 信息并协助他们明确干预的优先事项。拟议的系统将是 第一个在 GCC 的整个过程中提供决策支持，从睡眠问题筛查到退伍军人 对已确定的病症进行集中治疗。 具体目标和方法：在目标 1 中，我们将采用半结构化访谈的方式采访退伍军人、提供者、 和政策制定者确定以证据为基础、以退伍军人为中心的管理的障碍和促进因素 脑震荡后的睡眠状况。在目标 2 中，我们将利用目标 1 中利益相关者的意见来制定 决策支持系统（即仪表板、决策辅助）和培训材料。我们还将使用手动图表 进行审查以验证临床仪表板向退伍军人提供可操作信息的准确性 和护理点的提供者。在目标 3 中，我们将评估利益相关者的反馈，以评估可行性和 决策支持系统和相关培训材料的可接受性。将组件呈现给 利益相关者（例如退伍军人）；我们将使用混合方法设计来征求反馈，并利用该反馈来 完善原型和材料，直到满足可行性和可接受性标准。 该拟议项目的交付成果包括可行、可接受且经过验证的支持工具 能够确保患有脑震荡后睡眠状况的退伍军人获得基于证据的、退伍军人 集中护理。调查结果将使后续申请 VA RR&D Merit IIR 成为可能，该 IIR 会检查 决策支持系统对退伍军人接受优质护理及其功能的有效性 恢复。