Developing a Team-Delivered Intervention for Smoking and Hazardous Drinking for Primary Care Veterans with Cardiovascular Diseases

许多患有心血管疾病的退伍军人(30.4%)继续从事增加的行为 心血管事件和早期死亡的风险，如吸烟或危险饮酒。而退伍军人事务部 几个旨在帮助退伍军人戒烟或戒酒/减少饮酒的计划，在服务方面存在缺口 没有准备好接受以变化为基础的治疗，但继续吸烟或酗酒的退伍军人。弗吉尼亚州 患者看护团队(PACTS)每年对所有患者进行酒精和烟草使用筛查，因此 PACT平台是接触患有心血管疾病的退伍军人的理想方式，他们吸烟和/或酗酒。通过 初级保健精神健康整合(PCMHI)倡议，精神和行为健康提供者是 Embedded提供有效的、以证据为基础、以退伍军人为中心的行为健康干预 共同出现的行为健康问题和医疗问题。教育和自我监督 干预措施是以证据为基础的，并增加了吸毒者改变行为的意图，以及 此外，还改善了患者因素，包括参与度、接受行为健康转诊的意愿、 和自我管理策略。这项研究建议的重点是调整这些证据的要素- 专门针对基于协定的退伍军人管理局环境的干预措施，以吸引尚未准备好改变的退伍军人 吸烟和/或饮酒。这种干预旨在增加改变的意向，并可能提高 停止和参与以变革为基础的计划。这项干预将填补护理方面的空白，并有可能 改善PACT中看到的退伍军人的健康和寿命。 Julie Gass博士是临床心理学家和综合医疗中心(CIH)的博士后研究员， 退伍军人精神健康卓越中心负责通过PCMHI改善退伍军人医疗保健。这个 这个职业发展奖-2(CDA-2)的目的是促进Gass博士向独立的 HSR&D研究员，长期目标是通过研究以下方法的有效性来改善退伍军人的健康 以证据为基础、以退伍军人为中心的干预措施，以解决常见的行为和医疗问题 在PACT患者中。CDA-2的短期目标是获得正式培训、专家指导、 和研究经验，以促进退伍军人事务部HSR&D职业生涯，专注于改善干预措施和合同 为被诊断患有心血管疾病而吸烟和/或危险饮酒的退伍军人提供程序。CDA-2将 为Gass博士(在烟草治疗/研究方面有经验)提供(1)随机对照试验设计方面的必要培训， 实施和数据分析；(2)PC中的团队护理；(3)简短的酒精治疗；(4)定性 对干预发展的分析；以及(5)赠款精神，这将使她能够领导这三个项目 包括CDA-2研究计划。 由于任何新的干预措施对PACT和患者来说都是可获得和可行的，这一点很重要 研究将使用现有的文献、利益相关者的反馈和仔细的试验来开发最可行的 和以患者为中心的干预。干预措施将在该项目中以两种模式试行：PACT Team- 交付和PCMHI交付。CDA-2的具体目标如下。目标1，由试点数据和 系统的文献综述，是对地方和国家的利益相关者和专家进行的定性研究 了解参与联合任命的首选项、障碍和促进者，并改进 干预；目标2旨在以小样本测试这种干预，并做出必要的 目标3是在PACT中对手册进行试点测试，以获得对可接受性和 循证物质使用干预技术在现实世界临床实践中的可行性。 CDA-2的结果将为提交HSR&D关于更大RCT的优秀建议提供信息，该建议将于 第三年末。

Many Veterans (30.4%) with cardiovascular diseases (CVDs) continue to engage in behaviors that increase risk of cardiovascular events and early mortality, such as smoking or hazardous drinking. While the VA has several programs designed to help Veterans quit smoking or quit/reduce drinking, there is a gap in service for Veterans who are not ready for change-based treatments but continue to smoke or drink hazardously. VA Patient Aligned Care Teams (PACTs) screen all patients annually for alcohol and tobacco use, and thus the PACT platform is an ideal way to reach Veterans with CVDs who smoke and/or drink hazardously. Through the Primary Care Mental Health Integration (PCMHI) initiative, mental and behavioral health providers are embedded to provide effective, evidence-based, Veteran-centered, behavioral health interventions for a variety of co-occurring behavioral health concerns and medical problems. Educational and self-monitoring interventions are evidence-based and increase substance users' intentions to make a behavior change, and additionally improve patient factors including engagement, willingness to accept behavioral health referrals, and self-management strategies. This research proposal focuses on adapting elements of these evidence- based interventions specifically for a PACT-based VA setting to appeal to Veterans not yet ready to change smoking and/or drinking. This intervention aims to increase intention to change and may improve rates of cessation and engagement with change-based programs. The intervention will fill a gap in care and potentially improve the health and longevity of Veterans seen in PACT. Dr. Julie Gass is a clinical psychologist and postdoctoral fellow at the Center for Integrated Healthcare (CIH), a VA Mental Health Center of Excellence charged with improving Veteran healthcare through PCMHI. The purpose of this Career Development Award-2 (CDA-2) is to facilitate Dr. Gass's transition into an independent HSR&D investigator with a long-term objective of improving Veterans' health by studying the effectiveness of evidence-based, Veteran-centered interventions for commonly co-occurring behavioral and medical concerns within PACT patients. The short-term objective of this CDA-2 is to obtain formal training, expert mentorship, and research experience to facilitate a VA HSR&D career focused on improving interventions and PACT processes for Veterans who smoke and/or drink hazardously while diagnosed with CVDs. The CDA-2 will provide Dr. Gass (who has experience in tobacco treatment/research) with needed training in (1) RCT design, implementation, and data analysis; (2) team-based care in PC; (3) brief alcohol treatments; (4) qualitative analysis for intervention development; and (5) grantsmanship, which will allow her to conduct the three projects comprising the CDA-2 research plan. As it is important that any new intervention be accessible and feasible for the PACT and the patient, this research will use the extant literature, stakeholder feedback, and careful piloting to develop the most feasible and patient-centered intervention. The intervention will be piloted in this project in two modes: PACT team- delivered and PCMHI-delivered. Specific Aims of this CDA-2 are as follows. Aim 1, informed by pilot data and systematic literature review, is a qualitative study both of local and national stakeholders and experts to understand the preferences, barriers, and facilitators to engaging in conjoint appointments, and to refine the intervention; Aim 2 is designed to test this intervention in a small sample and make any necessary modifications; and Aim 3 is a pilot test of the manual in PACT to obtain feedback on the acceptability and feasibility of using evidence-based substance use intervention techniques in real-world clinical practice. Results of the CDA-2 will inform submission of an HSR&D merit proposal for a larger RCT to be submitted by the end of Year 3.