Health Care Utilization of Veterans Receiving Supported Employment

背景：伊拉克和阿富汗战争（OIF/OEF）退伍军人经历了反复部署- 相关的压力因素，使他们面临健康状况的风险，可能对其部署后产生负面影响 重新调整就业是成功重返社会的一个关键指标，但法语国家组织/持久自由行动的退伍军人 比文职人员更有可能就业，将工作困难和失业视为障碍 重新适应平民生活其他挑战包括精神疾病，包括创伤后 创伤后应激障碍（PTSD），据估计影响了大约20%的OIF/OEF退伍军人。中 在2010财年接受VA护理的5%最昂贵的患者中，17%有PTSD诊断。其中，他们 住院患者的累积行为住院时间为3.6天，门诊使用包括18.6精神 健康就诊，1.8次急诊就诊，6.5次初级保健就诊和5.2次专科就诊。 OIF/OEF退伍军人的失业和与服务有关的残疾有可能增加VA 急性护理服务利用率，这可能会对VA资源造成压力并产生长期影响，因为 OIF/OEF队列可能会使用VA服务60年以上。帮助退伍军人的干预措施 复苏和重返就业正在扩大在弗吉尼亚州，但很少有人知道这些证据是如何- 基于干预措施和随后的重返工作岗位影响卫生服务利用模式， 患有创伤后应激障碍的失业退伍军人本研究旨在收集这些证据，为以下方面的政策和做法提供信息： 为患有PTSD的退伍军人提供最有效的职业康复计划。 方法：本研究将评估近期失业退伍军人的卫生服务利用， PTSD的诊断，他们被随机分配接受个人安置和支持（IPS）或 过渡性工作（TW）。IPS是一种基于证据的支持就业模式， 以人为本，病人为导向的职业康复方法。VA IPS已提供给 患有严重精神疾病的退伍军人和那些无家可归但无法接触到的人 初步诊断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，VA合作社 研究计划（CSP）启动了一项多中心随机对照试验，比较IPS的有效性 在就业结果、PTSD症状、自尊方面， 和生活质量。这个庞大的，前瞻性随机的，地理上多样化的失业群体 患有PTSD的退伍军人代表了一个独特的机会，可以更多地了解IPS对医疗保健的影响 利用率本研究的目的是：1）比较退伍军人创伤后应激障碍患者的急性护理利用情况 前瞻性随机分配至IPS与TW; 2）比较高强度服务（即住院， 艾德，辅助，住宅）服务和门诊服务的退伍军人与创伤后应激障碍随机分配到 IPS与TW; 3）评估IPS相对于TW在患有PTSD的退伍军人中的成本效益。 意义：尽管IPS实施了十年，VA内部也有世界级的病历系统， 尚未进行研究，以评估IPS与VA内TWP相比对卫生保健的影响 PTSD人群中的服务利用率。然而，减少急性护理服务的有力证据 在美国和国际随机临床试验中随机分配至IPS的严重精神疾病患者中 临床试验迫使我们更多地了解IPS在VA环境和PTSD人群中的作用。作为更多的证据 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 减少高强度急症护理服务的使用及潜在的成本效益。这是第一次 鉴于其及时性、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（IPS/TW）和杰出的研究团队。

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.