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

背景：患有轻度创伤性脑损伤(MTBI)的退伍军人睡眠状况风险很高(失眠； 阻塞性睡眠呼吸暂停(阻塞性睡眠呼吸暂停综合征[OSA])，这会扰乱睡眠质量，破坏恢复。辨证论治 使用VA/DoD临床实践指南(CPG)管理失眠和 OSA(睡眠CPG)可以为退伍军人脑震荡后的恢复带来广泛的好处。 意义：睡眠CPG规定了以证据为基础的睡眠状况管理工作流程， 包括：1)筛查睡眠问题；2)评估睡眠状况；3)提供证据- 以治疗为基础。此外，睡眠CPG包括一项建议，即退伍军人和提供者合作 选择经验性支持的治疗方法，以确保护理符合退伍军人的偏好(即，退伍军人- 中心护理)。然而，退伍军人接受指南-一致性护理的情况存在差异(GCC) 脑震荡后睡眠状况的部分原因是：1)无法获得指南推荐的实践 护理点(PoC)；以及，2)由于高度 退伍军人个人喜好的本质。实施策略可以使GCC和便利 退伍军人的恢复，通过提供：1)退伍军人和提供者关于指南的信息-推荐 PoC的实践；以及，2)结构化支持，以促进以退伍军人为中心的护理。然而，这样的战略 还没有得到广泛的开发或实施。拟议的项目将解决康复方面的这一差距。 通过开发决策支持系统来照顾那些患有mTBI和睡眠状况的人。该系统将是 由两个互补的工具组成。首先，它将包括一个临床仪表板，用于提取患者级别的数据 在PoC转化为可操作的信息，提供有关以下方面的决策支持：1)睡眠筛查 问题；2)评估以发现失眠和/或阻塞性睡眠呼吸暂停综合症；以及3)推荐指南-一致性 根据临床表现选择治疗方案。其次，决策援助将促进两国之间的合作 提供者和退伍军人促进选择符合指南的治疗建议 病人的个人喜好。这将通过为退伍军人提供必要的 提供信息，并协助他们澄清干预的优先事项。拟议的系统将是 首先在GCC的整个团队中提供决策支持，从睡眠问题筛查到退伍军人- 对已识别的疾病进行集中治疗。 具体目标和方法：在目标1中，我们将使用对退伍军人、提供者、 和政策制定者确定以证据为基础、以老兵为中心的管理的障碍和促进者 脑震荡后睡眠状况。在目标2中，我们将利用来自目标1的利益相关者的意见来制定 决策支持系统(即仪表盘、决策辅助工具)和培训材料。我们还将使用手动海图 审查以验证临床仪表板向退伍军人提供可操作信息的准确性 以及护理地点的提供者。在目标3中，我们将评估利益相关者的反馈意见，以评估可行性和 决策支持系统和相关培训材料的可接受性。在将组件展示给 利益相关者(例如，退伍军人)；我们将使用混合方法设计来获取反馈并使用该反馈来 改进原型和材料，直到达到可行性和可接受性标准。 此建议项目的交付内容包括可行、可接受且经过验证的支持工具 有能力确保患有脑震荡后睡眠状况的退伍军人接受基于证据的退伍军人- 集中护理。调查结果将使后续申请VA RR&D Merit IIR能够检查 决策支持系统对退伍军人接受质量护理及其功能的影响 恢复。

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.