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

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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.