Organizational and Patient Factors Related to Polytrauma/TBI Patient Outcomes

描述（由申请人提供）： 背景：自2001年以来，大约有200万部队被部署到持久自由行动/伊拉克自由行动。服役人员返回时有各种身体和精神状况。大约15-19%的返回者被诊断患有创伤性脑损伤（TBI），这与情感，认知，躯体感觉和前庭症状有关。轻度TBI后的一个主要问题是脑损伤对精神疾病的影响，如创伤后应激障碍（PTSD），焦虑和抑郁。鉴于这些疾病的频繁合并症，临床医生在区分和治疗生理和心理表现方面很困难。由于VA的多发性创伤（PT）/TBI护理的组织结构，提供者可能会治疗身体（例如，TBI）和精神（例如，创伤后应激障碍（PTSD）的健康症状彼此隔离。在这一群体中，身体和精神后遗症的普遍性需要促进跨学科沟通和协调的组织结构，以更好地满足患者的多种需求。更好的协调与各种环境中更好的临床结局相关，包括VA。目的：重点关注为OEF/OIF退伍军人提供护理的VA多创伤护理系统多创伤网络站点（PNS）和多创伤支持诊所团队（PSCT），我们将同时研究组织因素，特别是结构整合（即组织和物理结构）和协调流程（即编程、反馈、关系协调）和与医疗保健利用和患者结局中的PT/TBI临床差异相关的患者相关因素，比如重新融入社区和对医疗保健的满意度。第二个目标是关注患者结局的性别差异。为了解决我们的主要目标，我们将解决四个研究问题（RQ）：RQ 1）如何PNS和PSCTs之间和之间的协调的三个措施，当考虑结构整合的指数？RQ 2）患者特征、结构整合和协调过程变量是否能预测患者利用率？利用率是否与TBI状态和转诊相关 创伤性脑损伤评估诊所停了吗RQ 3）患者特征、利用率、结构整合和协调过程在多大程度上预测了患者重返社区的结果和对医疗保健的满意度？RQ 4）根据RQ 3的结果，实现组织特征和患者特征相结合以获得更好的患者结局的障碍和促进因素是什么？方法：这是一项混合方法研究，包括三个阶段。第1阶段是一项前瞻性定量研究，将通过网络调查检查PNS和PSCT员工之间的PT/TBI诊所结构整合和协调过程。第2阶段将涉及对一个评价TBI的大型OEF/OIF队列进行回顾性管理数据库审查。使用VHA管理数据库，我们将确定一个退伍军人样本（基于8个PNS和16个PSCT，第1阶段有足够的应答率），以检查他们在TBI评价后90天的医疗保健利用情况。这一阶段还将包括对这些持久自由行动/伊拉克自由行动退伍军人进行前瞻性调查，调查内容包括：（a）人口统计学;（B）健康状况;（c）重返社区;（d）对退伍军人事务部医疗服务的满意度。在第3阶段，我们将（a）从第2阶段中选择8个PNS，并根据第2阶段的社区重新融合调查措施，（B）确定PSCT的前4名和后4名，以便我们可以与PT/TBI患者医疗保健提供者进行定性访谈，以更深入地了解这些研究中心的组织因素和协调流程。

DESCRIPTION (provided by applicant): Background: Since 2001, approximately 2 million troops have been deployed to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Service members are returning with a variety of physical and psychiatric conditions. Approximately 15-19% of returnees have been diagnosed with traumatic brain injury (TBI), which is associated with affective, cognitive, somatosensory, and vestibular symptoms. A major concern following mild TBI is the effect of brain injury on psychiatric conditions, such as posttraumatic stress disorder (PTSD), anxiety, and depression. Given the frequent comorbidity of these disorders, clinicians struggle in distinguishing between and treating the physical and psychological manifestations. Because of VA's organizational structure for polytrauma (PT)/TBI care, providers could potentially treat physical (e.g., TBI) and mental (e.g., PTSD) health symptoms in isolation from one another. The pervasiveness of physical and psychiatric sequelae in this cohort necessitates organizational structures that facilitate communication and coordination across disciplines to better address patients' multiple needs. Better coordination has been associated with better clinical outcomes in various settings, including in VA. Objectives: Focusing on the VA Polytrauma System of Care Polytrauma Network Sites (PNSs) and Polytrauma Support Clinic Teams (PSCTs) that provide care for OEF/OIF Veterans, we will examine simultaneously organizational factors, specifically structural integration (i.e. organizational and physical structures) and coordination processes (i.e. programming, feedback, relational coordination) and patient- related factors that are associated with PT/TBI clinic differences in healthcare utilization and patient outcomes, like community reintegration and satisfaction with health care. A secondary aim is to focus on gender differences in patient outcomes. To address our primary goal, we will address four research questions (RQs): RQ1) How do PNSs and PSCTs differ among and between themselves on three measures of coordination, when indices of structural Integration are considered? RQ2) Do patient characteristics, structural integration and coordination processes variables predict patient utilization? Is utilization associated with TBI status and referrals from the TBI evaluation clinic stop? RQ3) To what degree do patient characteristics, utilization, and structural integration and coordination processes predict differences in the patient outcomes of community reintegration and satisfaction with health care? RQ4) Based on the outcome of RQ3, what are the barriers to and facilitators of achieving the combinations of organizational characteristics and patient characteristics associated with better patient outcomes? Methods: This is a mixed methods study consisting of three phases. Phase 1 is a prospective quantitative study that will examine the PT/TBI clinic structural integration and coordination processes among employees of the PNSs and PSCTs via web survey. Phase 2 will involve a retrospective administrative database review of a large OEF/OIF cohort that was evaluated for TBI. Using VHA administrative databases, we will identify a Veteran sample (based on 8 PNSs and 16 PSCTs with adequate response rates from Phase 1) to examine their healthcare utilization 90 days post-TBI evaluation. This phase will also include a prospective survey of these OEF/OIF Veterans on (a) demographics, (b) health status, (c) community reintegration, and (d) satisfaction with VA healthcare services. In Phase 3, we will (a) select the 8 PNSs from Phase 2 and, based on the Phase 2 community reintegration survey measures, (b) identify the top 4 and bottom 4 performing PSCTs so that we may conduct qualitative interviews with PT/TBI patient healthcare providers to obtain a richer understanding of the organizational factors and coordination processes at these sites.