Developing a Shared Decision-Making Support Tool to Promote Evidence-based Treatment for Veterans with Post-concussive Sleep Conditions

背景：患有轻度创伤性脑损伤（mTBI）的退伍军人睡眠状况（失眠; 阻塞性睡眠呼吸暂停[OSA]），这会破坏睡眠质量并破坏恢复。识别和治疗 使用VA/DoD临床实践指南（CPG）管理失眠的睡眠状况， OSA（睡眠CPG）可以为退伍军人的脑震荡后恢复产生广泛的好处。 意义：睡眠CPG规定了睡眠状况管理的循证工作流程， 包括：1）筛查睡眠问题; 2）评估睡眠状况; 3）提供证据- 基于治疗。此外，睡眠CPG包括退伍军人和提供者合作的建议 选择经验支持的治疗方法，以确保护理符合退伍军人的偏好（即，老兵- 中心护理）。然而，在退伍军人接受指南一致性护理（GCC）方面存在差异， 脑震荡后睡眠状况部分原因是：1）缺乏指南推荐的实践， 护理点（Point-of-Care）;以及，2）与促进以退伍军人为中心的护理相关的挑战， 退伍军人的个人偏好。实施战略可以使海湾合作委员会发挥作用， 退伍军人的恢复，提供：1）退伍军人和供应商的信息，有关指南建议 实践中的医疗保健;和，2）结构化的支持，以促进退伍军人为中心的护理。然而，这些战略 还有待广泛开发或实施。拟议的项目将解决康复方面的这一差距。 通过开发决策支持系统来照顾那些患有mTBI和睡眠状况的人。该系统将 由两个互补的工具组成。首先，它将包括一个临床仪表板，可以提取患者级别的数据 转化为可操作的信息，提供以下方面的决策支持：1）睡眠筛查 问题; 2）评估以检测失眠和/或OSA;以及，3）推荐与指南一致的 根据临床表现选择治疗方案。第二，决策辅助将促进 提供者和退伍军人促进选择指南一致的治疗建议， 患者的个人偏好。这将通过为退伍军人提供必要的 信息，并协助他们澄清其干预的优先事项。拟议的系统将是 第一个在GCC的连续体中提供决策支持，从睡眠问题筛查到退伍军人- 集中治疗确定的条件。 具体目标和方法：在目标1中，我们将使用与退伍军人，供应商， 和决策者，以确定障碍和促进者，以证据为基础，退伍军人为中心的管理， 脑震荡后的睡眠状况在目标2中，我们将利用目标1中的利益相关者的意见， 决策支持系统（即，仪表板、决策辅助）和培训材料。我们也将使用手动图表 审查以验证临床仪表板向退伍军人提供可操作信息的准确性 和医护人员的信息在目标3中，我们将评估利益相关者的反馈，以评估可行性， 决策支持系统和相关培训材料的可接受性。在将组件呈现给 利益相关者（例如，退伍军人）;我们将使用混合方法设计来获得反馈，并使用这些反馈来 改进原型和材料，直到满足可行性和可接受性标准。 此建议项目的可验证内容包括可行、可接受且经过验证的支持工具 能够确保有脑震荡后睡眠状况的退伍军人获得基于证据的退伍军人- 中心护理调查结果将使随后的VA RR&D Merit IIR申请能够审查 决策支持系统对退伍军人接受优质护理的有效性及其功能 复苏

Background: Veterans with mild traumatic brain injury (mTBI) are at high risk for sleep conditions (insomnia; obstructive sleep apnea [OSA]), which disrupt sleep quality and undermine recovery. Identifying and treating such sleep conditions using the VA/DoD clinical practice guideline (CPG) for the management of insomnia and OSA (Sleep CPG) can produce wide-ranging benefits for Veterans’ post-concussive recovery. Significance: The Sleep CPG specifies an evidence-based workflow for management of sleep conditions, including: 1) screening for sleep problems; 2) assessing for sleep conditions; and, 3) delivering evidence- based treatments. Further, the Sleep CPG includes a recommendation that Veterans and providers collaborate to select empirically supported treatments to ensure that care aligns with Veterans’ preferences (i.e., Veteran- centered care). However, there exists variability in Veterans’ receipt of guideline-concordant care (GCC) for post-concussive sleep conditions due in part to: 1) lack of access to guideline-recommended practices at the point-of-care (PoC); and, 2) challenges associated with facilitating Veteran-centered care due to the highly individualized nature of Veterans’ preferences. Implementation strategies can enable GCC and facilitate Veterans’ recovery by providing: 1) Veterans and providers with information regarding guideline-recommended practices at the PoC; and, 2) structured support to facilitate Veteran-centered care. However, such strategies have yet to be widely developed or implemented. The proposed project will address this gap in rehabilitative care for those with mTBI and sleep conditions by developing a decision support system. The system will be comprised of two complementary tools. First, it will include a clinical dashboard that distills patient-level data into actionable information at the PoC, providing decision support with respect to: 1) screening for sleep problems; 2) assessments to detect insomnia and/or OSA; and, 3) recommending guideline-concordant treatment options based on clinical presentation. Second, a decision aid will facilitate collaboration between providers and Veterans to promote selection of guideline-concordant treatment recommendations that align with patients’ personal preferences. This will be accomplished by providing Veterans with necessary information and assisting them with clarifying their priorities for intervention. The proposed system will be the first to offer decision support across the continuum of GCC, from screening for sleep problems to Veteran- centered treatment of identified conditions. Specific Aims and Methodology: In Aim 1, we will use semi-structured interviews with Veterans, providers, and policymakers to identify barriers and facilitators to evidence-based, Veteran-centered management of post-concussive sleep conditions. In Aim 2, we will leverage stakeholder input from Aim 1 to develop a decision support system (i.e., dashboard, decision aid) and training materials. We will also use manual chart review to validate the accuracy with which the clinical dashboard provides actionable information to Veterans and providers at the point-of-care. In Aim 3, we will evaluate stakeholder feedback to assess the feasibility and acceptability of the decision support system and associated training materials. After presenting components to stakeholders (e.g., Veterans); we will use a mixed-methods design to elicit feedback and use that feedback to refine the prototype and materials until feasibility and acceptability criteria are met. Deliverables from this proposed project include a feasible, acceptable, and validated support tool capable of ensuring that Veterans with post-concussive sleep conditions receive evidence-based, Veteran- centered care. Findings will enable a subsequent application for a VA RR&D Merit IIR that examines the effectiveness of the decision support system on Veterans’ receipt of quality care and their functional recovery.