Cognitive-Behavioral Therapy for Chronic Pain: do Modifications Affect VEterans or implementatioN (CBT-CP MAVEN)

实施循证实践（EBP）是退伍军人健康管理局的优先事项 (VHA)和其他医疗系统。支持EBP的实施被视为一种重要手段， 确保退伍军人得到始终如一的高质量和适当的照顾。认知行为疗法 慢性疼痛（CBT-CP）是一种EBP，被认为是疼痛跨学科治疗的核心， 因此，VHA已投入大量资源，用于CBT-CP的全系统培训和认证。 尽管有大量的投资，但实际上对CBT-CP的实施一无所知 经过初步培训和认证，并根据其他EBP的实施情况，有充分的理由 相信修改经常发生，对退伍军人护理质量的影响未知。为了 防止浪费重要的退伍军人事务部资源和错过改善退伍军人慢性疼痛的机会 治疗，对CBT-CP进行了哪些修改的经验性理解，为什么要进行这些修改，以及 对实施的后续影响（包括退伍军人疼痛结局）至关重要。 我们的项目将包括对CBT-CP供应商进行VHA范围的调查，以评估所做的常见修改 在现场进行CBT-CP（目标1）。这项调查还将用于确定潜在的参与者， 提供者修改CBT-CP（目标2）的动机以及修改对 退伍军人成果（目标3a）和CBT-CP实施（目标3b）。 目标1将通过全国调查实现。这些数据还将用于目标2的定向征聘 和3.将对目标1的受访者和接受其护理的退伍军人进行分层随机抽样， CBT-CP修改及其效果的前瞻性自然观察研究。临床医生将 在基线和随访时完成关于修改的半结构化访谈。我们会研究 退伍军人结局的变化与修改的类型和程度之间的关联。执行将是 通过覆盖、有效性、采用、实施和维护（RE-AIM）的透镜进行评估。 RE-AIM变量将通过记录审查/管理数据、退伍军人访谈， 和临床医生自我报告。 对目标1的分析将是描述性的。为了检验供应商动机与 在目标2中的修改，我们将使用皮尔逊的相关性，以及关于原因的采访回应， 将使用归纳分析来分析修改。多水平混合效应模型将用于 检查退伍军人结果的修改和变化之间的关系（目标3）。 结果将提供有关当前CBT-CP实施工作影响的重要信息， 这可能会影响供应商的行为，并有助于最大限度地提高生产性修改相关的积极 退伍军人的成果。

The implementation of evidence-based practices (EBPs) is a priority for the Veterans Health Administration (VHA) and other healthcare systems. Supporting EBP implementation is seen as a crucial means by which to ensure that Veterans receive consistently high-quality and appropriate care. Cognitive- behavioral therapy for chronic pain (CBT-CP) is an EBP that is considered central to the interdisciplinary treatment of pain, and consequently VHA has invested substantial resources into system-wide training and certification for CBT-CP. Despite this substantial investment, practically nothing is known regarding the implementation of CBT-CP following initial training and certification, and based on implementation of other EBPs, there is good reason to believe that modification occurs frequently, with unknown impact on quality of Veterans' care. In order to prevent the waste of crucial VA resources and missed opportunities to improve Veterans' chronic pain treatment, an empirical understanding of what modifications are made to CBT-CP, why they are made, and the subsequent effects on implementation (including Veteran pain outcomes), is essential. Our project will include a VHA-Wide survey of CBT-CP providers that will assess common modifications made to CBT-CP in the field (Aim 1). This survey will also be used to identify participants in a prospective observational study of provider motivations to modify CBT-CP (Aim 2) as well as the effects of modification on Veteran outcomes (Aim 3a) and CBT-CP implementation (Aim 3b). Aim 1 will be achieved through a national survey. These data will also be used to target recruitment for Aims 2 and 3. A stratified random sampling of Aim 1 respondents and Veterans receiving their care will be selected for a prospective naturalistic observational study of CBT-CP modifications and their effects. Clinicians will complete semi-structured interviews regarding modification at baseline and follow-up. We will examine the association between change in Veteran outcomes and type and extent of modifications. Implementation will be assessed through the lens of Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM). RE-AIM variables will be assessed via a combination of record review/administrative data, Veteran interviews, and clinician self-report. Analyses of Aim 1 will be descriptive in nature. In order to test the relationship between provider motivation and modification in Aim 2, we will use Pearson's correlations, and interview responses regarding reasons for modification will be analyzed using inductive analyses. Multi-level mixed effects models will be used to examine the relationship between modification and change in Veteran outcomes (Aim 3). Results will provide vital information regarding the impact of current CBT-CP implementation efforts, factors which may affect provider behavior, and help maximize productive modifications associated with positive Veteran outcomes.