WRIISC as a Model of Care for Chronic Multisymptom Illness

 描述（由申请人提供）： 患有慢性多症状疾病（CMI）的海湾战争退伍军人（GWVs）对退伍军人健康管理局（VHA）护理的不满程度是没有CMI的退伍军人的两倍。这表明需要确定有效的以病人为中心的护理这些退伍军人的关键组成部分。治疗CMI的挑战可能集中在这样一个事实上，即关于CMI的原因一直存在争议。不一致，或不一致，患者和提供者之间的疾病的理解（疾病的看法）与其他人群的护理不满。除了对护理的满意度外，疾病感知被认为是CMI患者结局的关键决定因素。疾病感知占GWVs与CMI残疾变异的33%。目前尚不清楚的是，医疗服务提供者应如何解决疾病认知问题。试图改变具有CMI“适应不良”疾病感知的GWVs的治疗通常具有较差的依从性或低疗效。一个创新的方法是假设病人是他们经验的专家，提供者是医学专家，这两者都是改善护理所必需的。因此，提供者需要与患者合作，以发展个性化的一致的疾病认知。在患有其他慢性疾病的患者中（例如，糖尿病），与其提供者具有一致疾病感知的患者更满意，并且具有更好的健康结果。这是因为当患者和提供者以同样的方式了解疾病时，他们会制定患者想要遵守的有效治疗计划。战争相关疾病和伤害研究中心（WRIISC）是一个专门的诊所，为部署退伍军人与CMI。WRIISC提供者寻求与患者合作，以调整疾病的认知。超过97%的退伍军人在WRIISC看到他们的护理满意，但它是不知道，如果这种满意度是由于一致的疾病的看法，或者如果这种满意度可能最终提高遵守建议，为未来的利用和自我管理，并降低残疾。如果发现一致的疾病感知可以改善患有CMI的GWV的健康结局，则可以通过WRIISC与环境卫生之间的现有合作以及每个设施的部署后综合护理倡议临床冠军将这种方法传播给VHA提供者，以改善所有患有CMI的GWV的护理。本申请提出了一项观察性前瞻性研究，以检查GWVs与CMI和提供者之间疾病感知的一致性程度与健康结果之间的关系。在WRIISC看到的100个GWV与CMI的临床遭遇，以及VHA初级保健医生看到的100个GWV与CMI的临床遭遇将被录音。将使用观察者评级系统和疾病一致性问卷测量患者对疾病感知的一致性。健康结果将在遭遇后一周，三个月和一年进行测量。将与30名具有CMI的GWV进行定性访谈。其目的是确定GWVs与CMI和提供者之间的疾病感知的一致性程度与随着时间的推移结果的改善之间的关系。第二个目的是比较WRIISCs和普通VA初级保健的疾病感知启发和各种结果的程度。最后，确定用于引出GWVs的疾病感知的沟通策略提供者，并在疾病感知中产生一致性。

 DESCRIPTION (provided by applicant): Gulf War Veterans (GWVs) with Chronic Multi-Symptom Illness (CMI) are twice as likely to be dissatisfied with Veterans Health Administration (VHA) care as Veterans without CMI. This suggests the need to identify the critical components of effective patient-centered care for these Veterans. The challenges of treating CMI likely center on the fact that there is continuing debate about the cause(s) of CMI. Disagreement, or non-concordance, between patients' and providers' understanding of illness (illness perceptions) are related to dissatisfaction with care n other populations. Beyond satisfaction with care, illness perceptions are thought to be the key determinant of outcomes for patients with CMI. Illness perceptions account for 33% of the variability in disability for GWVs with CMI. What is not known is how providers should address illness perceptions. Treatments that have sought to change GWVs with CMI "maladaptive" illness perceptions have generally suffered from poor adherence or low efficacy. An innovative approach is to assume patients are experts of their experience and providers are medical experts and that both are needed to improve care. Thus providers need to work with patients to develop individualized aligned illness perceptions. Among patients with other chronic illnesses (e.g., diabetes), patients who have concordant illness perceptions with their providers are more satisfied and have better health outcomes. This is because when patients and providers understand the illness in the same way together they create effective treatment plans to which patients want to adhere. The War Related Illness and Injury Study Center (WRIISC) is a specialized clinic for deployed Veterans with CMI. WRIISC providers seek to collaborate with a patient to align illness perceptions. Over 97% of Veterans seen at the WRIISC are satisfied with their care, yet it is not known if this satisfaction is due to concordant illness perceptions or ifthis satisfaction may ultimately improve adherence to recommendations for future utilization and self-management, and lower disability. If concordant illness perceptions were found to improve health outcomes for GWVs with CMI, this approach could be disseminated to VHA providers through existing collaborations between WRIISC and environmental health and post- deployment integrated care initiative clinical champions at each facility, to improve care for all GWVs with CMI. This application proposes an observational prospective study to examine the relationship between degree of concordance in illness perceptions between GWVs with CMI and providers and health outcomes. Clinical encounters of 100 GWVs with CMI seen at the WRIISCs, and 100 GWVs with CMI seen by a VHA Primary Care Physician will be audio recorded. Patients' perceived concordance of illness perceptions will be measured with an observer rating system and by using the Illness Concordance Questionnaire. Health outcomes will be measured one week, three months and one year after the encounter. Qualitative interviews will be conducted with 30 of the GWVs with CMI. The aims are to determine the relationship between degree of concordance in illness perceptions between GWVs with CMI and providers and improvements in outcomes over time. The second aim is to compare the extent of illness perception elicitation and various outcomes at WRIISCs and usual VA primary care. Finally, identify the communication strategies providers used to elicit GWVs' illness perceptions and generate concordance in illness perceptions.