Development of a Tailored Intervention to Increase Veteran Enrollment in Cardiac Rehabilitation

背景：退伍军人事务部（VA）卫生服务研究与发展职业发展 奖项重新提交是一个五年计划，将使候选人，工作人员心脏病专家和专家， 心脏康复（CR）在VA田纳西河流域医疗保健系统，开发和实施 干预措施，以增加退伍军人的CR入学率。CR是一种门诊计划，包括处方药 运动和心脏危险因素教育是心血管疾病患者的基本疗法。 该提案将制定一项量身定制的干预措施，以增加退伍军人在CR中的入学率。 意义/影响：CR广泛未得到充分利用，不到20%的合格患者入组CR 方案全国。退伍军人的CR利用率特别低，只有10%的合格退伍军人 参加CR项目。尽管CR转诊率在过去十年中大幅上升， 入学人数保持不变。必须研究退伍军人中CR入学的障碍， 并针对这些个别障碍制定干预措施。 创新：申请人将开发一种量身定制的干预措施，用于使用肥胖- 相关行为干预试验模型，一个干预发展的概念模型，以及 信息-动机-行为技能模型，一种允许个体定制的行为改变理论。 将这些模型联系起来将产生关于行为干预方法的新知识， 创新的临床干预，可以提供护士和其他临床工作人员在VA设施。的 建议的干预措施与当前的VA计划保持一致，支持CR入组， 方便退伍军人（包括VA CR计划，非VA CR计划和基于家庭的CR计划）。 具体目标：目标1和2包括一项顺序解释性混合方法研究，以评估 在退伍军人中注册CR。目标1的目的是量化100名退伍军人的CR障碍 使用先前验证的关于心脏康复的信念， 量表（BACRS）。目标2的目的是通过以下方式揭示门诊CR入组的其他障碍： 定性访谈30名退伍军人从目标1谁没有参加CR。目标3关注迭代 开发定制干预措施，以增加3组（每组5例）住院患者的门诊CR入组率 退伍军人，表征干预的可行性和可接受性。在目标4中，有针对性的干预将 在25名因缺血性心脏病住院的退伍军人的非随机分组中进行概念验证测试 疾病申请人假设这些退伍军人将在临床上显著改善 干预后的BACRS总分，代表CR的感知障碍减少。 方法学：目标1将通过评估 BACRS汇总评分和子量表。在目标2中，申请人将使用强度抽样， 选择个人BACRS子量表得分最低（以及感知的CR障碍最高）的退伍军人， 目标1队列进行半结构化定性访谈。目标3将使用目标1和目标2的混合数据， 一系列形成性评价，为定制干预的迭代开发提供信息。在目标4中， 将在干预前后进行，描述干预对感知的影响。 通过BACRS汇总评分衡量的CR入组障碍。 实施/后续步骤：申请人将使研究活动与QUERI实施保持一致 制定路线图并召集利益攸关方参与小组，以确保制定有针对性的干预措施 最大限度地推广到其他VA设施。拟议研究的结果将为广泛的 与退伍军人CR入组相关的计划，并将用于进行以下随机临床试验： 在研究者发起的研究应用程序的背景下进行定制干预。

Background: This Veterans Affairs (VA) Health Services Research & Development Career Development Award resubmission is a five-year plan that will enable the candidate, a staff cardiologist and specialist in cardiac rehabilitation (CR) at the VA Tennessee Valley Healthcare System, to develop and implement interventions to increase CR enrollment in Veterans. CR is an outpatient program including prescriptive exercise and cardiac risk factor education that is an essential therapy for patients with cardiovascular disease. This proposal will develop a tailored intervention to increase Veteran enrollment in CR. Significance/Impact: CR is widely underutilized, with less than 20% of eligible patients enrolling in CR programs nationally. CR utilization is particularly low among Veterans, with only 10% of eligible Veterans enrolling in CR programs. Though CR referral rates have risen substantially over the past decade, CR enrollment has remained static. It is imperative to study barriers to CR enrollment among Veterans that have already been referred to CR and develop interventions tailored to these individual barriers. Innovation: The applicant will develop a tailored intervention for increasing CR enrollment using the Obesity- Related Behavioral Intervention Trials model, a conceptual model for intervention development, as well as the information-motivation-behavioral skills model, a theory of behavior change that allows individual tailoring. Linking these models will produce new knowledge regarding behavioral intervention methodology as well as an innovative clinical intervention that can be delivered by nurses and other clinical staff at VA facilities. The proposed intervention aligns with current VA initiatives by supporting CR enrollment wherever is most convenient for Veterans (including VA CR programs, non-VA CR programs, and home-based CR programs). Specific Aims: Aims 1 and 2 comprise a sequential explanatory mixed methods study to evaluate barriers to CR enrollment among Veterans. The purpose of Aim 1 is to quantify barriers to CR in 100 Veterans hospitalized with ischemic heart disease using the previously validated Beliefs About Cardiac Rehabilitation Scale (BACRS). The purpose of Aim 2 is to reveal additional barriers to outpatient CR enrollment through qualitative interviews in 30 Veterans from Aim 1 who did not enroll in CR. Aim 3 focuses on the iterative development of a tailored intervention to increase outpatient CR enrollment in 3 groups of 5 hospitalized Veterans, characterizing the intervention’s feasibility and acceptability. In Aim 4, the tailored intervention will undergo proof-of-concept testing in a non-randomized group of 25 Veterans hospitalized with ischemic heart disease. The applicant hypothesizes that these Veterans will have a clinically significant improvement in BACRS summary scores after the intervention, representing a decrease in perceived barriers to CR. Methodology: Aim 1 will quantitate the burden of CR barriers among Veterans by evaluating distributions of BACRS summary scores and subscales. In Aim 2, the applicant will use intensity sampling to purposefully select Veterans with the lowest individual BACRS subscale scores (and highest perceived barriers to CR) from the Aim 1 cohort for semi-structured qualitative interviews. Aim 3 will use mixed data from Aims 1 and 2 and serial formative evaluations to inform the iterative development of a tailored intervention. In Aim 4, the BACRS will be administered before and after the intervention, characterizing the intervention’s effect on perceived barriers to CR enrollment as measured by the BACRS summary score. Implementation/Next Steps: The applicant will align the study activities with the QUERI Implementation Roadmap and convene a Stakeholder Engagement Panel to ensure that the tailored intervention is developed with maximum generalizability to other VA facilities. Findings from the proposed study will inform a wide range of initiatives related to CR enrollment among Veterans and will be used to conduct a randomized clinical trial of the tailored intervention within the context of an Investigator Initiated Research application.