Controlled Trial of Tele-Support and Education for Womens Health Care in CBOCs

描述(由申请人提供)： 项目背景/理论基础：退伍军人在退伍军人中所占比例迅速上升。虽然女性退伍军人有权得到与男性同等的护理，但她们得到的护理质量可能较低，部分原因是退伍军人的初级保健(PC)工作人员照顾妇女的经验有限，特别是她们的性别状况。这一劳动力可能在社区门诊诊所(CBOC)面临特别挑战，在那里可能不容易获得妇女健康(WH)专业知识。CBOC PC提供商(PCP)通常有少量女性退伍军人，使这些提供商难以保持其WH知识和技能。为了确保对女性退伍军人的高质量护理，退伍军人管理局授权在每个退伍军人设施中指定妇女保健提供者(DWHP)，并为这些提供者建立强化培训机会--“妇女保健迷你住院医师”。虽然这些一次性培训在提供标准水平的专门卫生培训方面非常有价值，但由于知识会随着时间的推移而减弱，因此是不够的。随着时间的推移，需要重新加强连续教育，以产生和保持知识或技能的长期增长。此外，还需要更多的支持，例如加强初级保健医生和专家之间的沟通，以实现和维持质量收益。目标：我们建议测试“DWHP支持”，这是一种旨在改善以CBOC为基础的DWHP提供全面卫生保健的干预措施。DWHP支持结合了：1)先进的WH系列患者教育，随着时间的推移，使DWHP接触到WH病例和问题的深度和广度；以及2)CBOC DWHP与退伍军人医学中心专家之间的互动交流，以“及时”支持DWHP WH护理。这种干预是由技术支持的，并以虚拟方式提供。我们假设，DWHP支持将提高CBOCs中WH护理的质量和效率。我们的具体目标是：目标1：评估DWHP支持对WH护理质量和效率的影响，在准试验性对照试验中，比较干预VA区域(VISN)和普通护理VISN中的CBOC；目标2：探索DWHP支持在改变DWHP行为和自我评估的WH知识、技能和自我效能方面的影响；目标3：评估对DWHP支持及其使用的态度、实施的专家时间以及其他可能影响DWHP支持的有效性、可持续性和传播的特征；目标4：开发工具来测量VA的WH护理质量。方法：我们将进行一项前瞻性的准实验对照试验，将DWHP支持与CBOC DWHP的常规护理进行比较。这将是一项双VISN研究，其中干预与控制的分配水平将是VISN。我们将使用混合方法分析方法来衡量干预措施的效果，同时评估干预措施的实施过程和使用情况。我们将实施现有的循证卫生绩效指南，以衡量VA卫生保健的质量。预期影响：这项建议旨在通过为妇女保健提供者设计的基于技术的教育和互动交流干预措施来改善CBOCs的妇女保健服务。为了衡量干预措施的有效性，该项目将开发卫生保健质量衡量标准，这将是其他退伍军人管理局努力改善卫生保健的宝贵工具。我们在有效性和实施方面的发现可能会影响退伍军人管理局在其他临床条件和其他特殊人群中使用技术支持的干预措施的方法和使用。

DESCRIPTION (provided by applicant): Project Background/Rationale: Women Veterans are a rapidly growing proportion of VA patients. While entitled to receive care equivalent to their male counterparts, women Veterans may receive lower quality care, in part due to a VA primary care (PC) workforce that has limited experience caring for women, particularly their gender-specific conditions. This workforce may be especially challenged in community-based outpatient clinics (CBOCs), where access to women's health (WH) expertise may not be readily available. CBOC PC providers (PCPs) typically have small caseloads of women Veterans, making it difficult for these providers to maintain their WH knowledge and skills. To ensure quality care for women Veterans, VA mandated designated WH providers (DWHPs) in every VA facility, and instituted intensive training opportunities-"WH mini- residencies"-for these providers. Although highly valuable in delivering a standard level of specialized WH training, these one-time trainings are not sufficient, as knowledge attenuates over time. Serial education re- enforcement over time is needed to produce and maintain long-term gains in knowledge or skills. Furthermore, additional supports, such as enhanced communication between PCPs and specialists, are necessary to achieve and sustain quality gains. Objectives: We propose to test "DWHP Support," an intervention designed to improve CBOC-based DWHP delivery of comprehensive WH care. DWHP Support combines: 1) advanced WH serial patient-based education that exposes DWHPs, over time, to a depth and breadth of WH cases and issues; and 2) interactive communication between CBOC DWHPs and VA Medical Center-based specialists for "just in time" support of DWHP WH care. The intervention is technology-supported and delivered virtually. We hypothesize that DWHP Support will improve the quality and efficiency of WH care in CBOCs. Our specific aims are: Aim #1: To evaluate the effect of DWHP Support on WH care quality and efficiency, in a quasi-experimental controlled trial, comparing CBOCs in an intervention VA region (VISN) to a usual care VISN; Aim #2: To explore the impact of DWHP Support in changing DWHP behavior and self-rated WH knowledge, skills, and self-efficacy; Aim #3: To assess attitudes about DWHP Support and its use, specialist time for its implementation, and other features that could influence DWHP Support's effectiveness, sustainability and spread; Aim #4: To develop tools to measure quality of WH care in VA. Methods: We will conduct a prospective, quasi-experimental controlled trial of DWHP Support versus usual care for CBOC DWHPs. This will be a two-VISN study where the level of assignment to intervention versus control will be the VISN. We will use a mixed methods analytic approach to measure the intervention's effect after 1 year, while also evaluating the implementation process and use of the intervention. We will operationalize existing evidence-based WH performance guidelines for quality measurement of VA WH care. Anticipated Impact: This proposal aims to improve WH care in CBOCs with a technology-based educational and interactive communication intervention designed for WH providers. To measure the intervention's effectiveness, this project will develop WH quality measures that will be valuable tools for other VA efforts to improve WH care. Our findings on effectiveness and implementation could influence VA's approach and use of technology-supported interventions for other clinical conditions and in other special populations.