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（CVD）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。虽然VA 一些旨在帮助退伍军人戒烟或戒烟/减少饮酒的计划， 退伍军人谁是没有准备好改变为基础的治疗，但继续吸烟或饮酒有害。VA 患者调整护理团队（PACTs）每年对所有患者进行酒精和烟草使用筛查，因此 PACT平台是接触吸烟和/或饮用危险饮料的心血管疾病退伍军人的理想方式。通过 初级保健心理健康整合（PCMHI）倡议，心理和行为健康提供者 嵌入式提供有效的，以证据为基础的，以退伍军人为中心的行为健康干预措施， 行为健康问题和医疗问题同时发生教育和自我监测 干预措施是以证据为基础的，并增加物质使用者改变行为的意图， 另外改善患者因素，包括参与度，接受行为健康转诊的意愿， 自我管理策略。这项研究计划的重点是调整这些证据的要素- 专门针对基于PACT的VA设置的基于干预措施，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愿，并可能提高 停止和参与基于变革的方案。这项干预措施将填补护理方面的空白， 改善PACT中看到的退伍军人的健康和寿命。 Julie Gass博士是综合医疗保健中心（CIH）的临床心理学家和博士后研究员， 一个卓越的VA心理健康中心，负责通过PCMHI改善退伍军人医疗保健。的 这个职业发展奖的目的-2（CDA-2）是为了促进博士Gass的过渡到一个独立的 HSR&D调查员，长期目标是通过研究以下措施的有效性来改善退伍军人的健康状况： 以证据为基础，以退伍军人为中心的干预措施，用于常见的共同发生的行为和医疗问题 在PACT患者中。该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VA HSR&D职业生涯的重点是改善干预措施和PACT 诊断患有心血管疾病时吸烟和/或饮用危险饮料的退伍军人。CDA-2将 为Gass博士（具有烟草治疗/研究经验）提供（1）RCT设计， 实施和数据分析;（2）PC中基于团队的护理;（3）短暂的酒精治疗;（4）定性 干预发展分析;以及（5）granecraft，这将使她能够开展三个项目 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， 研究将利用现有的文献、利益相关者的反馈和仔细的试点，以开发最可行的 以病人为中心的干预。该项目将以两种模式试行干预措施：PACT团队- 交付和PCMHI交付。该CDA-2的具体目标如下。目标1，以试点数据为依据， 系统性文献综述，是对当地和国家利益相关者和专家进行的定性研究， 了解参与联合任命的偏好、障碍和促进者，并完善 目标2旨在在小样本中测试这种干预措施， 目标3是在PACT中对手册进行试点测试，以获得关于可接受性的反馈， 在现实世界的临床实践中使用循证药物使用干预技术的可行性。 CDA-2的结果将为提交更大规模RCT的HSR&D优点提案提供信息， 第三年年底。

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.