Anxiety diagnostic accuracy in VA primary care mental health integration settings: Identifying barriers and facilitators to inform a learning health care system

对退伍军人医疗保健的预期影响：提供高质量的医疗保健需要准确的 及时诊断。美国国家医学院声称，“改善诊断过程并不是 这不仅是可能的，而且代表了道德，专业和公共卫生的必要性。识别因素 影响诊断准确性对于改进诊断过程是至关重要的。拟定的研究将 识别与VHA初级保健心理健康整合中焦虑诊断错误相关的因素 （PCMHI）和专业精神卫生（MH）设置，并解决HSR&D优先领域“精神和 行为健康”和“医疗保健系统的变革”以及整个医疗保健部门的优先领域“学习医疗保健” 系统” 项目背景：VHA对当前焦虑诊断的特定决定因素的信息很少 实践和作出诊断的社会技术背景。未指明的焦虑症是 VHA中最常见的焦虑相关诊断，但通常是诊断错误。2017财年，408，250名退伍军人 入组VHA的患者诊断为未指明的焦虑症，未指明的焦虑占 70%的焦虑症诊断在PCMHI。然而，这些诊断中的大多数都是错误的， 只有不到3%的退伍军人被诊断患有未指明的焦虑症，符合DSM-5的标准。准确 诊断是基于证据的医疗保健的基础，77%的退伍军人被诊断患有未指明的疾病。 焦虑符合特定焦虑或创伤相关障碍（广泛性焦虑障碍）诊断标准 [GAD创伤后应激障碍[PTSD，38%];惊恐障碍，20%;社交焦虑障碍，20%）。 诊断准确性对于获得适当的服务至关重要。只有32%的退伍军人 与退伍军人相比，焦虑症患者在诊断后的一年内接受了心理健康服务。 被诊断为广泛性焦虑症（60%）、惊恐障碍（67%）和社交焦虑障碍（88%）。一个错误的 未指明的焦虑症的诊断是接受适当的循证护理的障碍， 创伤后应激障碍、广泛性焦虑症和恐慌症等疾病。 项目目标：拟议的3年多中心研究将使用定量和定性混合方法， 根据更安全的Dx框架，识别与以下因素相关的系统、提供者和患者层面的因素： VHA PCMHI和专业MH设置中的焦虑诊断特异性。了解这些因素 在焦虑诊断过程中的互动对于确定诊断过程中的点至关重要， 介入 项目方法：拟议项目的目标将通过三项主要活动实现， 使用混合的定性和定量方法进行。Aim 1将使用来自 企业数据仓库（CDW），用于识别与以下因素相关的系统、提供者和患者层面的因素： PCMHI和专业MH设置中的焦虑诊断特异性。目标2将包括定性访谈 与PCMHI和专业MH提供者一起了解他们对焦虑障碍和促进因素的看法 诊断特异性目标3将确定障碍，焦虑症诊断的特异性，在每个阶段的 更安全Dx框架概述的诊断过程。这一目标将通过图表审查实现， 对诊断为未指明的焦虑症的患者进行诊断性访谈，以及对严重事件 与PCMHI和专业MH提供商进行访谈。 下一步：本研究的结果将使研究团队能够设计和测试定制的干预措施 促进心理健康提供者准确和及时地诊断焦虑和创伤相关疾病， 老兵

Anticipated Impacts on Veteran's Healthcare: The provision of high quality healthcare requires accurate and timely diagnosis. The National Academy of Medicine asserts that “Improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.” Identifying factors influencing diagnostic accuracy is essential to improving the diagnostic process. The proposed study will identify factors associated with anxiety diagnostic errors in VHA primary care mental health integration (PCMHI) and specialty mental health (MH) settings, and addresses HSR&D priority areas "Mental and Behavioral Health” and “Health Care Systems Change” and the ORD-wide priority area “Learning Health Care System” Project Background: VHA has little information about specific determinants of current anxiety diagnostic practices and the sociotechnical context in which diagnoses are made. Unspecified anxiety disorder is the most common anxiety-related diagnosis in VHA but is often a diagnostic error. In FY2017, 408,250 Veterans enrolled in the VHA carried an unspecified anxiety disorder diagnosis, and unspecified anxiety accounted for 70% of anxiety diagnoses in PCMHI that year. However, the majority of these diagnoses are erroneous as fewer than 3% of Veterans diagnosed with unspecified anxiety meet DSM-5 criteria for this disorder. Accurate diagnosis is foundational to evidence-based healthcare, and 77% of Veterans diagnosed with unspecified anxiety meet diagnostic criteria for a specific anxiety or trauma-related disorder (generalized anxiety disorder [GAD, 44%]; posttraumatic stress disorder [PTSD, 38%]; panic disorder, 20%; social anxiety disorder 20%). Diagnostic accuracy is critical to accessing appropriate services. Only 32% of Veterans with unspecified anxiety disorder received mental health services in the year following diagnosis, compared to Veterans diagnosed with GAD (60%), panic disorder (67%), and social anxiety disorder (88%). Thus, an erroneous diagnosis of unspecified anxiety disorder is a barrier to receipt of appropriate evidence-based care for specific disorders such as PTSD, GAD, and panic disorder. Project Objectives: The proposed, 3-year, multisite study will use mixed quantitative and qualitative methods, informed by the Safer Dx framework, to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in VHA PCMHI and specialty MH settings. Understanding how these factors interact in the anxiety diagnostic process is crucial to identifying point(s) in the diagnostic process at which to intervene. Project Methods: The aims of the proposed project will be achieved through three major activities that will be carried out using mixed, qualitative and quantitative, methods. Aim 1 will use administrative data from the Corporate Data Warehouse (CDW) to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in PCMHI and specialty MH settings. Aim 2 will consist of qualitative interviews with PCMHI and specialty MH providers to understand their perspectives on barriers and facilitators to anxiety diagnostic specificity. Aim 3 will identify barriers to anxiety diagnostic specificity in each phase of the diagnostic process outlined by the Safer Dx framework. This aim will be achieved through chart reviews and diagnostic interviews of patients diagnosed with unspecified anxiety disorder, as well as critical incident interviews with PCMHI and specialty MH providers. Next Steps: Findings from this study will position the research team to design and test a tailored intervention to facilitate mental health providers' accurate and timely diagnosis of anxiety- and trauma-related disorders for Veterans.