Optimizing treatment response in VA Specialized Intensive/Inpatient PTSD programs

背景：创伤后应激障碍(PTSD)影响大约23%的退伍军人和 产生巨大的心理、身体和经济负担。尽管大多数患有创伤后应激障碍的退伍军人 在门诊治疗的基础上，退伍军人管理局有39个专门的强化/住院创伤后应激障碍计划(SIPP)。 旨在治疗需要更多重症监护和严密监护的高需求退伍军人。治疗方法 有创伤后应激障碍的VA患者中只有1%的人参加了SIPPS 但他们占退伍军人事务部专门创伤后应激障碍护理预算的33%。此外，尽管有这些代价，许多 在SIPPS接受治疗的患者可能只会经历PTSD症状的轻微改善。因此， 医学研究所最近呼吁制定策略来改善VA创伤后应激障碍的治疗结果 一般治疗和住院计划，明确退伍军人管理局需要仔细评估和 解决接受住宿和其他创伤后应激障碍治疗的退伍军人对治疗反应不佳的问题。 目标：CDA的目标是通过确定个人和计划层面的因素来优化创伤后应激障碍护理 与住院治疗反应差有关，这将极大地提高退伍军人管理局的能力 针对这些高需求、高成本的个人并改进治疗方法。目标1将确定 全国居民项目治疗反应的个人和项目水平的预测因子。目标2将 使用定性方法进一步阐明与创伤后应激障碍治疗反应差相关的因素 在VISN 10计划和全国3个高绩效项目和3个项目中对患者、提供者和管理员进行访谈 低绩效计划(根据平均症状变化和14年内再次入院的患者百分比 出院天数)。目标3将试行对现有治疗或卫生服务干预措施的适应 根据最初研究目标的结果，高绩效站点的治疗实践数据，以及对 由指导小组、业务合作伙伴和前线工作人员组成的专家小组的可行性。 方法：本研究将以资源、生活事件和心理变化理论为指导 各州。目标1将使用全国临床的多水平建模来评估不良反应的预测因素 东北项目评估中心收集的信息。感兴趣的变量将包括个人- 水平资源和因素，如合并症、社会背景资源(例如低社会支持)，以及 方案资源，如循证治疗的可用性。目标2将利用定性分析 方法通过采访患者和提供者来评估个体和项目水平的反应预测因素。 目标3将包括在VISN 10住院治疗创伤后应激障碍项目中对60名患者进行的可行性试验。 候选人：PI的长期目标是成为独立的退伍军人健康服务调查员 制定和评估计划，以改善患有严重和难以治疗的创伤后应激障碍患者的预后 提高创伤后应激障碍的护理质量。在这次CDA期间，PI将为研究计划奠定基础 关注糟糕的创伤后应激障碍治疗反应，同时培养卫生服务方法方面的专业知识。私人侦探将 完成以下培训活动：(1)多层次建模、方案评估和其他卫生服务方法； (2)定性和混合方法；(3)实施科学和成本分析。拟议的研究 培训活动将为PI提供技能，以改善对退伍军人的创伤后应激障碍护理。 环境：PI将受益于支持培训和研究的丰富资源，这些资源包括 可通过弗吉尼亚州HSR&D创新中心、密歇根大学精神病学系、 卫生保健政策与创新研究所和公共卫生学院。她将充分利用 这些机会和支持和协调的指导团队，丰富了她目前和建议的 研究。拟议的CDA研究具有非常重要的意义，涉及关键的退伍军人管理局和订单优先领域 包括精神健康服务研究和创伤后应激障碍的关注点研究。

Background: Posttraumatic Stress Disorder (PTSD) affects approximately 23% of returning Veterans and produces significant psychological, physical, and economic burdens. Although most Veterans with PTSD are treated on an outpatient basis, the VA has 39 Specialized Intensive/Inpatient PTSD programs (SIPPs) designed to treat high-needs Veterans who require more intensive and closely monitored care. The treatment of patients enrolled in SIPPs is extremely costly; only 1% of VA patients with a PTSD diagnosis enroll in SIPPs but they account for 33% of VA's budget for specialized PTSD care. Furthermore, despite these costs, many patients undergoing treatment in SIPPs may experience only modest improvements in PTSD symptoms. Thus, the Institute of Medicine has recently called for strategies to improve treatment outcomes of VA PTSD treatment in general and residential programs specifically, making it clear the VA needs to carefully assess and address poor treatment response among Veterans receiving residential and other PTSD treatment. Objectives: The goal of this CDA is to optimize PTSD care by identifying individual- and program-level factors associated with poor treatment response in residential programs, which will greatly enhance the VA's ability to target and improve treatment approaches for these high-need, high-cost individuals. Aim 1 will identify individual- and program-level predictors of treatment response in residential programs nationwide. Aim 2 will further elucidate factors associated with poor PTSD treatment response, using a qualitative approach with patient, provider, and administrator interviews at a VISN 10 program and nationally at 3 high-performing and 3 low-performing programs (based on average symptom change and percent of patients readmitted within 14 days of discharge). Aim 3 will pilot an adaptation of an existing treatment or health services intervention based on findings from the initial study aims, data on treatment practices at high-performing sites, and assessment of feasibility from an expert panel consisting of the mentorship team, operational partners, and frontline staff. Methods: This research will be guided by the theory of Resources, Life Events and Changes in Psychological States. Aim 1 will assess predictors of poor response using multilevel modeling of nationwide clinical information collected by the Northeast Program Evaluation Center. Variables of interest will include individual- level resources and factors such as comorbidities, social contextual resources (e.g. low social support), and program resources such the availability of evidence-based treatments. Aim 2 will utilize qualitative analytic methods to assess individual and program-level predictors of response by interviewing patients and providers. Aim 3 will consist of a feasibility pilot conducted with 60 patients at a VISN 10 residential program for PTSD. Candidate: The PI's long-term goal is to become an independent VA health services investigator who develops and evaluates programs to improve outcomes for individuals with severe and difficult-to-treat PTSD and improve care quality for PTSD. During this CDA, the PI will build the foundation of a research program focusing on poor PTSD treatment response while building expertise in health services methods. The PI will complete training activities in: (1) multilevel modeling, program evaluation, and other health services methods, (2) qualitative and mixed methods, and (3) Implementation Science and cost analysis. The proposed research and training activities will provide the PI with the skills to inform improved PTSD care for Veterans. Environment: The PI will benefit from the wealth of resources supporting training and research that are available through the VA HSR&D Center of Innovation, the University of Michigan Department of Psychiatry, the Institute for Healthcare Policy and Innovation, and the School of Public Health. She will make full use of these opportunities and the supportive and coordinated mentorship team to enrich her current and proposed research. The proposed CDA research is highly significant and addresses key VA and ORD priority areas including mental health services research and advancing Point of Care Research in PTSD.