Health Care Utilization of Veterans Receiving Supported Employment

背景资料：伊拉克和阿富汗战争(OIF/OEF)退伍军人经历了反复部署- 相关的压力源，使他们面临健康状况的风险，这可能会对他们的部署后产生负面影响 重新调整。就业是成功重返社会的关键指标，但OIF/OEF退伍军人的比例较低 可能比文职人员更有可能被雇用，认为工作困难和失业是障碍 重新适应平民生活。其他挑战包括精神疾病，包括创伤后 应激障碍(PTSD)，据估计，大约20%的OIF/OEF退伍军人受到影响。在这些人中 在2010财年接受退伍军人管理局护理的最昂贵的患者中有5%，17%的患者被诊断为创伤后应激障碍。其中，他们的 住院患者的累计行为住院天数为3.6天，门诊患者的心理利用为18.6天 健康就诊、急诊科就诊1.8人次、初级保健就诊6.5人次、专科就诊5.2人次。 OIF/OEF退伍军人中的失业和与服务相关的残疾有可能增加VA 急性护理服务利用率，这可能会给退伍军人管理局资源带来压力并产生长期影响，因为 OIF/OEF队列可能会再使用退伍军人管理局服务60年。帮助退伍军人的干预措施 退伍军人事务部的复苏和重新就业正在扩大，但人们对这些证据如何--知之甚少。 以干预为基础的干预措施和随后的重返工作影响#年卫生服务利用模式 患有创伤后应激障碍的失业退伍军人。这项研究旨在收集这一证据，为 为患有创伤后应激障碍的退伍军人提供最有效的职业康复计划。 方法：本研究将评估最近失业的退伍军人的卫生服务利用情况。 随机化接受个人安置和支持(IPS)或 过渡工作(TW)。IPS是一种基于证据的支持性就业模式，它是一种自信的、 以人为本，以病人为主导的职业康复方法。Va IPS已可用于 患有严重精神疾病的退伍军人和无家可归但无法接触到的人 初诊为创伤后应激障碍的退伍军人。2013年，在戴维斯博士的领导下，弗吉尼亚州合作社 研究计划(CSP)启动了一项多点随机对照试验，比较了IPS的有效性 对患有创伤后应激障碍的退伍军人(n=541)在就业结果、创伤后应激障碍症状、自尊方面的影响 和生活质量。这一庞大的、预期随机的、地理上不同的失业群体 患有创伤后应激障碍的退伍军人代表着一个独特的机会，可以更多地了解IPS对医疗保健的影响 利用率。本研究的具体目的是：1)比较退伍军人和创伤后应激障碍患者的急性护理利用情况 前瞻性随机分为IPS和TW；2)比较高强度服务的成本(即住院患者、 在患有创伤后应激障碍的退伍军人中，急诊科服务和门诊服务被随机分配到 在患有创伤后应激障碍的退伍军人中，评估IPS相对于TW的成本效益。 意义：尽管在退伍军人事务部实施了十年的IPS和世界级的医疗记录系统， 还没有进行研究来评估退伍军人管理局内IPS和TWP对医疗保健的影响 创伤后应激障碍人群中的服务利用率。然而，急性护理服务减少的有力证据 来自美国和国际随机临床的严重精神疾病患者被随机纳入IPS 试验迫使我们更多地了解退伍军人和创伤后应激障碍人群中的IPS。随着更多的证据 关于IPS的临床有效性，利益相关者急切地想知道IPS是否有潜力 减少高强度急性护理服务的使用和潜在的成本效益。这是史无前例的 这项研究的及时性、规模(n=541)、前瞻性随机对照设计、VA设置、 诊断焦点(PTSD)，使用来自相当封闭的医疗保健系统(VA)的计算机化患者记录， 比较干预措施(IPS/TW)和杰出的调查团队。

Background: Iraq and Afghanistan war (OIF/OEF) Veterans have experienced repeated deployment- related stressors that put them at risk for health conditions that can negatively impact their post-deployment readjustment. Employment is a key indicator of successful reintegration, but OIF/OEF Veterans are less likely to be employed than their civilian counterparts, identifying difficulties at work and job loss as barriers to readjusting to civilian life. Additional challenges include psychiatric conditions, including posttraumatic stress disorder (PTSD), which is estimated to affect approximately 20% of OIF/OEF Veterans. Among the 5% costliest patients receiving VA care in fiscal year 2010, 17% had a PTSD diagnosis. Among these, their inpatient cumulative behavioral length of stay was 3.6 days, and outpatient utilization included 18.6 mental health visits, 1.8 emergency department visits, 6.5 primary care visits, and 5.2 subspecialty visits. Unemployment and service-connected disability in OIF/OEF Veterans has the potential to increase VA acute care service utilization, which may strain and have a long-term impact on VA resources, given that the OIF/OEF cohort will likely use VA services for six more decades. Interventions that assist Veterans in recovery and return to employment are expanding in the VA, but little is known about how these evidence- based interventions and subsequent return to work impacts the health service utilization patterns in unemployed Veterans with PTSD. This study seeks to gather this evidence to inform policy and practices in the delivery of the most effective vocational rehabilitation program for Veterans with PTSD. Methods: This study will evaluate the health service utilization among recently unemployed Veterans with a diagnosis of PTSD who have been randomized to receive either Individual Placement and Support (IPS) or Transitional Work (TW). IPS is an evidence-based model of supported employment, which is an assertive, person-centered, patient-driven approach to vocational rehabilitation. VA IPS has been available to Veterans with severe mental illness and to those who are homeless, but has not been accessible to Veterans with a primary diagnosis of PTSD. In 2013, under the leadership of Dr. Davis, VA Cooperative Studies Program (CSP) launched a multisite randomized controlled trial comparing the effectiveness of IPS to TWP for Veterans with PTSD (n=541) in terms of employment outcomes, PTSD symptoms, self-esteem and quality of life. This large, prospectively randomized, geographically diverse group of unemployed Veterans with PTSD represents a unique opportunity to learn more about the impacts of IPS on health care utilization. The specific aims of this study are to 1) compare the acute care utilization in Veterans with PTSD prospectively randomized to IPS versus TW; 2) compare the costs for high intensity services (i.e. inpatient, ED, domiciliary, residential) services and for outpatient services among Veterans with PTSD randomized to IPS versus TW; and 3) assess the cost-effectiveness of IPS relative to TW among Veterans with PTSD. Significance: Despite a decade of IPS implementation and a world-class medical record system within VA, no research has been conducted to evaluate the impact of IPS compared to TWP within VA on health care service utilization in a PTSD population. However, the strong evidence for reduction in acute care services among persons with serious mental illness randomized to IPS from US and international randomized clinical trials compels us to learn more about IPS in the VA setting and in a PTSD population. As more evidence emerges about the clinical effectiveness of IPS, stakeholders eagerly want to know if IPS has the potential to reduce the use of high intensity acute care services and potential cost effectiveness. This first-of-its-kind study is landmark given its timeliness, size (n=541), prospective randomized controlled design, VA setting, diagnostic focus (PTSD), use of computerized patient records from a fairly closed health care system (VA), comparative interventions (IPS/TW), and distinguished team of investigators.