Improving Care for Veterans by Understanding and Facilitating Transition to Recommended PTSD Treatment

背景：创伤后应激障碍（PTSD）是最常见的精神疾病之一 在退伍军人中。认知加工疗法（CPT）和长期暴露疗法（PE）被广泛应用于 在退伍军人健康管理局（VHA）作为推荐的PTSD治疗方法进行传播。尽管有这些 尽管如此，很少有9/11后被诊断患有PTSD的退伍军人开始CPT或PE。在少数退伍军人中， 对于接受这些治疗的退伍军人来说，CPT和PE很少是退伍军人接受的第一次治疗。一个共同 在实施研究中确定的治疗顺序，从“稳定治疗”开始， 心理社会和药物治疗，为CPT或PE准备退伍军人。现有研究的一个空白是 治疗顺序，特别是稳定治疗，如何影响CPT或PE的开始。 意义/影响：PTSD是HSR&D的优先条件，由于其实质性的负面生物心理社会 对退伍军人生活的影响。需要新的策略来提高参与度、保留率和改进 建议的创伤后应激障碍治疗的结果，并减少获得这种护理的差距。 了解如何最有效地结合联合收割机和序列创伤后应激障碍治疗是HSR&D确定的领域， 兴趣，以及VHA PTSD临床实践指南中确定的研究差距。 创新：尽管一直将稳定治疗确定为常见的VHA实践，但很少有研究 研究了这种治疗方法一种解决PTSD治疗现有局限性的新方法 交付涉及制定一项干预措施，既承认普遍存在， 稳定治疗，同时促进从稳定治疗及时过渡到CPT或PE。 具体目标：该CDA-2旨在改善VHA中PTSD服务的提供，同时 为我提供健康服务研究方法的培训，以支持我发展成为一名独立的 VHA研究员。本研究的目的是：（1）定性了解退伍军人和临床医生的心理健康状况 关于选择稳定化处理以及稳定化处理如何作为屏障或 过渡到CPT或PE的促进者;（2）开发并进行一项简短， 以退伍军人为中心的干预，以支持从稳定治疗过渡到CPT或PE;以及（3） 识别治疗序列中的社会人口学差异，并确定治疗序列如何 影响VHA中CPT或PE启动的时间。 方法：然后，我将对全国退伍军人样本（n=30）进行定性访谈， 临床医生（n=20;目标1）。使用快速定性分析程序，我将评估治疗顺序， 特别是稳定治疗，以及它们如何成为向CPT过渡的障碍或促进因素 和PE。然后，我将利用从目标1中获得的知识，制定一项卫生服务干预措施， 及时过渡到CPT或PE。我将在一项随机、务实的试点试验中测试这种干预措施， 干预（n=20）到常规治疗（n=20;目标2）。我会评估退伍军人中 开始干预后一年内的CPT或PE作为主要结局，可行性作为次要结局 结果。使用来自9/11后退伍军人的全国纵向队列的电子健康记录数据， 从2005年10月至2023年12月接受VHA PTSD治疗（预计n= 400，000），我将确定治疗顺序; 使用考克斯比例风险，了解治疗序列如何影响至CPT或PE开始的时间 回归;并根据社会人口统计学特征确定治疗序列中的差异（目标3）。 实施/后续步骤：我将把通过本提案获得的知识和培训应用于 HSR&D Merit应用程序通过多站点大规模测试开发的干预措施的益处 混合型第二类实用主义审判我将与心理健康办公室的组织伙伴合作， 自杀预防，以确保工作支持努力促进临床实践指南一致的护理。

Background: Posttraumatic stress disorder (PTSD) is one of the most common mental health diagnoses among Veterans. Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated in the Veterans Health Administration (VHA) as recommended PTSD treatments. Despite these efforts, few post-9/11 Veterans diagnosed with PTSD initiate CPT or PE. In the small percentage of Veterans who receive these therapies, CPT and PE are rarely the first treatment a Veteran receives. A common treatment sequence identified in implementation research, begins with “stabilization treatment,” combinations of psychosocial and medication treatments that prepare Veterans for CPT or PE. A gap in existing research is how treatment sequences, particularly stabilization treatment, influence initiation of CPT or PE. Significance/Impact: PTSD is an HSR&D priority condition due to its substantial negative biopsychosocial impact on Veterans lives. Novel strategies are needed to increase engagement, retention, and improve outcomes from recommended PTSD treatments, and to reduce disparities in access to this care. Understanding how to most effectively combine and sequence PTSD treatment is an HSR&D identified area of interest, and a research gap identified in the VHA PTSD clinical practice guideline. Innovation: Despite consistently identifying stabilization treatment as a common VHA practice, little research has investigated this treatment sequence. A novel approach to solving existing limitations in PTSD treatment delivery involves developing an intervention that both acknowledges the ubiquitous presence and benefits of stabilization treatment, while facilitating timely transition from stabilization treatment to CPT or PE. Specific Aims: This CDA-2 aims to improve delivery of PTSD services in the VHA, while simultaneously providing me with training in health services research methods to support my development into an independent VHA researcher. The proposed research aims are: (1) To qualitatively understand Veterans’ and clinicians’ perspectives on selecting stabilization treatments and how stabilization treatment serves as a barrier or facilitator of transition to CPT or PE; (2) To develop and conduct a randomized, pragmatic pilot trial of a brief, Veteran-centered intervention to support transition from stabilization treatment to CPT or PE; and (3) To identify sociodemographic disparities in treatment sequences and to determine how treatment sequences influence time to CPT or PE initiation across the VHA. Methodology: I will then conduct qualitative interviews with a national sample of Veterans (n=30) and clinicians (n=20; Aim 1). Using rapid qualitative analysis procedures, I will evaluate how treatment sequences, particularly stabilization treatment, are chosen and how they serve as a barrier or facilitator of transition to CPT and PE. I will then use knowledge gained from Aim 1 to develop a health services intervention that facilitates timely transition to CPT or PE. I will test this intervention in a randomized, pragmatic, pilot trial comparing the intervention (n=20) to treatment as usual (n=20; Aim 2). I will assess the proportion of Veterans who initiate CPT or PE within a year after beginning the intervention as a primary outcome and feasibility as a secondary outcome. Using electronic health record data from a national, longitudinal cohort of post-9/11 Veterans who received VHA PTSD treatment (anticipated n=400,000) from 10/05-12/23, I will identify treatment sequences; understand how treatment sequence impacts time to CPT or PE initiation using Cox proportional hazard regression; and identify disparities in treatment sequences based on sociodemographic characteristics (Aim 3). Implementation/Next Steps: I will apply the knowledge and training gained through this proposal to an HSR&D Merit application to test the benefits of the developed intervention on a large scale through a multisite hybrid type-II pragmatic trial. I will collaborate with organizational partners at the Office of Mental Health and Suicide Prevention to ensure that work supports efforts to promote clinical practice guideline-consistent care.