Implementation of Brief Treatments for Insomnia in Primary Care

 描述（由申请人提供）： 慢性失眠是退伍军人和军事人员转介心理健康服务报告最多的投诉之一。它与医学和精神疾病高度共病，并与显著增加的医疗保健利用和成本相关。尽管失眠的影响很大，但它仍然没有得到充分的治疗。当被发现时，失眠症最常在初级保健环境中使用药物治疗，而不是基于证据的心理治疗-失眠症的认知行为治疗（CBTI）-这是有效的，并推荐处方睡眠药物。然而，许多系统、提供者和患者层面的障碍，以及治疗相关的障碍，导致失眠的高患病率与CBTI的可及性之间存在差距。为了增加VA失眠行为治疗的可行性，关键是要确定哪些行为治疗最有效，以及哪些实施因素（例如，护理的障碍和促进因素）对患者和提供者将治疗纳入常规临床实践的影响最大。与CBTI相比，治疗时间更短（≤4个疗程），允许通过电话进行治疗，也可以由非博士水平的临床医生进行治疗（例如，护士）可能有助于克服限制获得失眠护理的障碍。简短的行为治疗的inflammation（BBTI）提供了治疗的灵活性，可以增加访问，是有效的退伍军人和军事人员。此外，BBTI的上述特点使其成为VA的初级保健患者对齐护理团队（PACTs）和初级保健心理健康整合（PC-MHI）倡议中协作，综合初级保健背景下的理想干预措施。将BBTI摄入PACTs可以有效地增加失眠治疗的机会，从而降低与慢性失眠相关的风险和负担。虽然有效，但尚不清楚BBTI是否能达到与CBTI相同的临床结果，CBTI是一种VA支持的循证心理治疗。此外，从提供者和患者的角度来看，与在PACTs中提供BBTI相关的实施因素仍然未知。在初级保健PACTs中广泛实施BBTI可能会对退伍军人的健康和医疗保健产生重大影响，但有必要确定哪种治疗-CBTI或BBTI-以最少的患者，提供者和系统障碍产生最佳结果。我的长期职业目标是成为VA HSR&D研究员，研究失眠行为治疗的传播和实施，以及减少失眠对退伍军人健康影响的方法。我提议的CDA将支持新的研究方法和分析策略的培训，以及向独立过渡所需的研究活动的开展。我的研究目标是：（1）进行BBTI与CBTI的先导性比较有效性试验;以及（2）进行定性需求评估，以确定与在基层护理PACTs中实施失眠行为治疗相关的因素。我提出的培训目标是：（1）熟练掌握比较有效性研究的定量方法和分析策略，包括：招募，结果测量和等效性分析;（2）发展卫生服务研究和实施科学的专业知识，包括理论框架的应用，以及实施试验的设计，实施和评估;及（3）学习卫生服务研究中使用的定性方法和分析的高级技能，包括：数据收集方法（例如，访谈，焦点小组），数据分析方法，以及使用软件进行数据分析。

 DESCRIPTION (provided by applicant): Chronic insomnia is among the most reported complaints of Veterans and military personnel referred for mental health services. It is highly comorbid with medical and psychiatric disorders, and is associated with significantly increased healthcare utilization and costs. Despite the significant impacts of insomnia, it remains under-treated. When identified, insomnia is most often treated in the primary care setting with pharmacotherapy, rather than evidence-based psychotherapy-Cognitive Behavioral Treatment for Insomnia (CBTI)-which is effective and recommended over prescription sleep medications. However, a number of system-, provider-, and patient-level barriers, as well as treatment-related barriers, contribute to the gap between the high prevalence of insomnia and access to CBTI. To increase the viability of behavioral treatments for insomnia in the VA, it is critical to determine which behavioral treatments are most effective, and which implementation factors (e.g., barriers and facilitators to care) most impact uptake of treatments by patients and providers into routine clinical practice. Compared to CBTI, a treatment that is shorter (≤4 sessions), allows for phone delivered treatment, and can also be delivered by non-doctoral level clinicians (e.g., nurses) may help to overcome barriers that limit access to insomnia care. Brief Behavioral Treatment of Insomnia (BBTI) offers the treatment flexibility that can increase access and is efficacious among Veterans and military personnel. Furthermore, BBTI's aforementioned characteristics make it an ideal intervention for delivery in the context of collaborative, integrated primary care within VA's Primary Care Patient-Aligned Care Teams (PACTs) and Primary Care-Mental Health Integration (PC-MHI) initiatives. Uptake of BBTI into PACTs could effectively and efficiently increase access to insomnia treatment and thus decrease the risks and burdens associated with chronic insomnia. Although efficacious, it is not known if BBTI achieves the same clinical outcomes as CBTI, a VA supported evidence-based psychotherapy. Additionally, the implementation factors associated with the delivery of BBTI in PACTs from the perspective of providers and patients remains unknown. Broad implementation of BBTI in Primary Care PACTs could have a significant impact on Veteran health and healthcare, but it is necessary to determine which treatment-CBTI or BBTI- yields the best outcomes with the least patient, provider, and system barriers. My long-term career goal is to be a VA HSR&D Investigator with a program of research on the dissemination and implementation of behavioral treatments for insomnia, and methods to decrease the impact of insomnia on Veteran health. My proposed CDA will support training in new research methods and analytic strategies, and the conduct of research activities necessary for transition to independence. My proposed Research Aims are: (1) to conduct a pilot comparative effectiveness trial of BBTI vs. CBTI; and (2) to conduct a qualitative needs assessment to identify factors associated with the implementation of behavioral treatments for insomnia in Primary Care PACTs. My proposed Training Aims are: (1) to gain proficiency in quantitative methods and analytic strategies for comparative effectiveness research, including: recruitment, measurement of outcomes, and equivalency analysis; (2) to develop expertise in health services research and implementation science, including the application of theoretical frameworks, and the design, conduct, and evaluation of implementation trials; and (3) to learn advanced skills in qualitative methods and analyses for use in health services research, including: data collection methods (e.g., interviews, focus groups), data analytic methods, and the use of software for data analysis.