Anxiety diagnostic accuracy in VA primary care mental health integration settings: Identifying barriers and facilitators to inform a learning health care system

对退伍军人医疗保健的预期影响：提供高质量的医疗保健需要准确 及时诊断。美国国家医学科学院断言，“改进诊断过程并不是 这是唯一可能的，但也代表了道德、职业和公共卫生的必要性。确定因素 影响诊断的准确性是改善诊断过程的关键。拟议的研究将 确定与VHA初级保健精神健康整合中的焦虑诊断错误相关的因素 (PCMHI)和专业精神卫生(MH)设置，并解决高铁和发展的优先领域“精神和 “行为健康”、“卫生保健系统变革”和全球优先领域“学习卫生保健” 系统“ 项目背景：VHA对当前焦虑症诊断的具体决定因素知之甚少 实践和作出诊断的社会技术背景。未指明的焦虑症是 VHA中最常见的与焦虑相关的诊断，但通常是诊断错误。2017财年，408,250名退伍军人 参加VHA的患者被诊断患有未指明的焦虑症，而不明原因的焦虑症 那一年PCMHI 70%的焦虑症被诊断出来。然而，这些诊断中的大多数是错误的，因为 在被诊断患有不明焦虑症的退伍军人中，只有不到3%的人符合这种疾病的DSM-5标准。准确 诊断是循证医疗的基础，77%的退伍军人被诊断为未指明的疾病 焦虑符合特定焦虑或创伤相关障碍(广泛性焦虑症)的诊断标准 [GAD，44%]；创伤后应激障碍[PTSD，38%]；惊恐障碍，20%；社交焦虑障碍，20%)。 诊断的准确性是获得适当服务的关键。只有32%的退伍军人患有未指明的疾病 与退伍军人相比，焦虑症在确诊后的一年里接受了心理健康服务 诊断为广泛性焦虑症(60%)、惊恐障碍(67%)和社交焦虑症(88%)。因此，一个错误的 未指明的焦虑症的诊断是接受适当的循证治疗的障碍 精神障碍，如创伤后应激障碍、广泛性AD和恐慌症。 项目目标：拟议的为期3年的多地点研究将使用定量和定性相结合的方法， 由更安全的Dx框架提供信息，以确定与以下各项相关的系统级、提供商级和患者级因素 VHA、PCMHI和专科MH设置中的焦虑症诊断特异性。了解这些因素是如何 焦虑诊断过程中的交互作用对于确定诊断过程中的点(S)至关重要 进行干预。 项目方法：拟议项目的目标将通过以下三项主要活动实现 采用定性与定量相结合的方法进行研究。AIM 1将使用来自 企业数据仓库(CDW)，识别与以下各项相关的系统级、提供商级和患者级因素 PCMHI和专科MH环境中焦虑症诊断的特异性。目标2将由定性访谈组成 与PCMHI和专业MH提供商一起了解他们对焦虑障碍和促进者的看法 诊断特异性。目标3将确定焦虑诊断特异性在每个阶段的障碍 SAFER Dx框架概述的诊断流程。这一目标将通过图表审查和 诊断为焦虑症和危重事件患者的诊断性访谈 与PCMHI和专业MH供应商的访谈。 下一步：这项研究的结果将使研究团队设计和测试量身定制的干预措施 促进精神健康提供者准确和及时地诊断与焦虑和创伤相关的障碍 退伍军人。

Anticipated Impacts on Veteran's Healthcare: The provision of high quality healthcare requires accurate and timely diagnosis. The National Academy of Medicine asserts that “Improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.” Identifying factors influencing diagnostic accuracy is essential to improving the diagnostic process. The proposed study will identify factors associated with anxiety diagnostic errors in VHA primary care mental health integration (PCMHI) and specialty mental health (MH) settings, and addresses HSR&D priority areas "Mental and Behavioral Health” and “Health Care Systems Change” and the ORD-wide priority area “Learning Health Care System” Project Background: VHA has little information about specific determinants of current anxiety diagnostic practices and the sociotechnical context in which diagnoses are made. Unspecified anxiety disorder is the most common anxiety-related diagnosis in VHA but is often a diagnostic error. In FY2017, 408,250 Veterans enrolled in the VHA carried an unspecified anxiety disorder diagnosis, and unspecified anxiety accounted for 70% of anxiety diagnoses in PCMHI that year. However, the majority of these diagnoses are erroneous as fewer than 3% of Veterans diagnosed with unspecified anxiety meet DSM-5 criteria for this disorder. Accurate diagnosis is foundational to evidence-based healthcare, and 77% of Veterans diagnosed with unspecified anxiety meet diagnostic criteria for a specific anxiety or trauma-related disorder (generalized anxiety disorder [GAD, 44%]; posttraumatic stress disorder [PTSD, 38%]; panic disorder, 20%; social anxiety disorder 20%). Diagnostic accuracy is critical to accessing appropriate services. Only 32% of Veterans with unspecified anxiety disorder received mental health services in the year following diagnosis, compared to Veterans diagnosed with GAD (60%), panic disorder (67%), and social anxiety disorder (88%). Thus, an erroneous diagnosis of unspecified anxiety disorder is a barrier to receipt of appropriate evidence-based care for specific disorders such as PTSD, GAD, and panic disorder. Project Objectives: The proposed, 3-year, multisite study will use mixed quantitative and qualitative methods, informed by the Safer Dx framework, to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in VHA PCMHI and specialty MH settings. Understanding how these factors interact in the anxiety diagnostic process is crucial to identifying point(s) in the diagnostic process at which to intervene. Project Methods: The aims of the proposed project will be achieved through three major activities that will be carried out using mixed, qualitative and quantitative, methods. Aim 1 will use administrative data from the Corporate Data Warehouse (CDW) to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in PCMHI and specialty MH settings. Aim 2 will consist of qualitative interviews with PCMHI and specialty MH providers to understand their perspectives on barriers and facilitators to anxiety diagnostic specificity. Aim 3 will identify barriers to anxiety diagnostic specificity in each phase of the diagnostic process outlined by the Safer Dx framework. This aim will be achieved through chart reviews and diagnostic interviews of patients diagnosed with unspecified anxiety disorder, as well as critical incident interviews with PCMHI and specialty MH providers. Next Steps: Findings from this study will position the research team to design and test a tailored intervention to facilitate mental health providers' accurate and timely diagnosis of anxiety- and trauma-related disorders for Veterans.