Evaluation of the Caring Letters Suicide Prevention Intervention after Removal of an Electronic Health Record Flag for Suicide Risk: An Effectiveness-Implementation Hybrid Type 2 Trial

移除电子健康记录自杀风险标记后关怀信自杀预防干预的评估：有效性-实施混合 2 型试验

• 批准号: 10753299
• 负责人: Mark A. Reger
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-04-01 至 2026-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10753299
• 关键词: Acute; Address; Aftercare; Caring; Catchment Area; Clinical; Clinical Practice Guideline; Clinical effectiveness; Communication; Country; Data; Decentralization; Effectiveness; Effectiveness of Interventions; Electronic Health Record; Eligibility Determination; Emergency department visit; Evaluation; Excision; Follow-Up Studies; Frequencies; Goals; Healthcare; Hospitalization; Incidence; Individual; Intervention; Interview; Joints; Judgment; Leadership; Letters; Mental Health; Meta-Analysis; Modeling; Nature; Outcome; Outpatients; Patients; Personal Satisfaction; Persons; Policies; Population; Population Intervention; Prevention program; Procedures; Program Evaluation; Provider; Public Health; Randomized; Reporting; Resources; Risk; Schedule; Series; Structure; Suicide; Suicide attempt; Suicide prevention; Testing; Time; Veterans; Veterans Health Administration; Work; acute care; clinical implementation; cohort; design; effectiveness testing; effectiveness/implementation design; effectiveness/implementation hybrid; high risk; high risk population; hybrid type 2 trial; implementation barriers; implementation facilitators; implementation fidelity; implementation strategy; improved; informant; mortality; prevention service; preventive intervention; programs; protective effect; randomized, clinical trials; reducing suicide; response; secondary analysis; suicidal behavior; suicidal patient; suicidal risk; suicide mortality; suicide rate

ABSTRACT In the electronic health record (EHR), the Veterans Health Administration (VHA) uses patient record flags during periods of high acute risk for suicide (e.g., following a suicide attempt) to alert clinicians and improve suicide prevention services. Unfortunately, recent analyses revealed that after these high-risk flags (HRFs) are discontinued based on clinical judgement, suicide rates remain high in the year that follows. This creates a suicide prevention challenge. To address this need, VHA facilities were required in 2020 to start implementing the Caring Letters suicide prevention intervention for this population. In the Caring Letters intervention, a series of messages are sent to individuals to communicate that they are not forgotten, and that people care about them and are concerned for their well-being. The messages also serve as a reminder that help is available. Multiple randomized clinical trials support the efficacy of Caring Letters for reducing suicide behaviors in acute care settings. The Joint Commission recently promoted Caring Letters, and the intervention is included in the VA/DoD suicide prevention Clinical Practice Guideline for acute care settings. Unfortunately, the mandate to use this intervention with Veterans with a discontinued HRF (VD-HRF) has faced many challenges. Less than half the facilities across the nation have implemented the program. For facilities that have implemented the program, several concerning fidelity problems have been identified, indicating that thousands of Veterans in those catchment areas are not receiving the intervention as intended. Therefore, we propose a partnered program evaluation between the VHA Suicide Prevention Program (SPP), and the proposed evaluation team to examine a new version of the intervention for this unique population. Specifically, the evaluation will randomize all VA facilities to either: (1) Centralized Caring Letters where all the work of administering Caring Letters is centralized with a single, national team (promoting high fidelity and compliance with the requirement), or (2) De-Centralized Caring Letters in which VA facilities continue their local procedures as usual during a 6- month delay before starting Centralized Caring Letters. We will conduct an effectiveness-implementation Hybrid Type 2 trial. As a Hybrid Type 2 trial, the study has dual primary goals. The first is to test the effectiveness of a Caring Letter campaign for VD-HRFs, a relatively new population for the intervention. The second goal is to evaluate the impact of adding an implementation strategy – centralizing the work of Caring Letters – to the existing strategy of mandating change. The evaluation will test two aims. In Aim 1, we will evaluate the effects of Caring Letters on clinical outcomes and VA clinical utilization rates. An exploratory aim will also examine rates of suicide attempts, all-cause mortality, and suicide for Veterans who receive Centralized Caring Letters compared to a historical cohort who received no Caring Letters. In Aim 2, we will evaluate the impact of adding the implementation strategy of centralizing the work of the intervention to the existing implementation strategy of mandating change. Using qualitative interviews, we will evaluate leadership, staff, and provider perspectives on the implementation and sustainability of Centralized Caring Letters. This will be one of the largest evaluations of a Caring Letters intervention ever conducted, and it will provide direct and actionable data to leadership to evaluate the impacts of this major prevention program.

抽象的 在电子健康记录（EHR）中，退伍军人健康管理局（VHA）使用患者记录标志 在高度急性危险的时期（例如自杀企图之后），以提醒临床医生并改善 预防自杀服务。不幸的是，最近的分析表明，在这些高风险标志（HRF）之后 根据临床判断而停产，随后的一年自杀率仍然很高。这会创建一个 预防自杀挑战。为了满足这一需求，在2020年需要VHA设施开始实施 对该人群的自杀式预防干预措施。在关怀的信件干预中，一个系列 消息发送给个人，以交流他们没有被遗忘，人们关心 他们并担心自己的幸福。这些消息还提醒您可以提供帮助。 多个随机临床试验支持关怀信件的效率，以减少急性的自杀行为 护理设置。联合委员会最近促进了关怀信，干预措施包括在 VA/DOD自杀预防急性护理环境的临床实践指南。不幸的是，任务 使用该干预措施与停产的HRF（VD-HRF）面临许多挑战。少于 全国一半的设施已经实施了该计划。对于已经实施的设施 计划，已经确定了有关忠诚问题的几个，表明成千上万的退伍军人 这些集水区没有按预期接受干预。因此，我们建议一个合作 VHA自杀预防计划（SPP）与拟议的评估团队之间的计划评估 检查该独特人群的新版本。具体而言，评估将 将所有VA的设施随机随机：（1）集中的关怀信件，所有管理关怀的工作 信件集中在一个国家团队中（促进高保真和遵守要求）， 或（2）在6--中，VA设施像往常一样继续其本地程序的偏心式关怀信件 在开始集中关怀信之前的一个月延迟。我们将进行有效的实施 混合2型试验。作为Hybrid 2型试验，该研究具有双重主要目标。首先是测试 VD-HRFS的关怀信运动的有效性，VD-HRF是一个相对新的干预措施。这 第二个目标是评估添加实施策略的影响 - 集中关怀工作 信件 - 实施更改的现有策略。评估将测试两个目标。在AIM 1中，我们将 评估关怀字母对临床结果和VA临床利用率的影响。探索性目标 还将检查接受退伍军人的自杀企图，全因死亡率和自杀率 与没有收到关怀信的历史群体相比，集中关怀的信件。在AIM 2中，我们将 评估添加将干预工作集中到将干预工作的实施策略的影响 现有的实施策略强制更改。使用定性访谈，我们将评估 对集中关怀的实施和可持续性的领导，员工和提供者的观点 信件。这将是有史以来有史以来进行干预的最大评估之一，它将 向领导力提供直接和可行的数据，以评估该主要预防计划的影响。