Improving and Sustaining Delivery of CPT for PTSD in Mental Health Systems

 描述(由申请人提供)：大规模实施循证心理疗法(EBP)，例如针对创伤后应激障碍的认知加工疗法(CPT)，可以对身心健康、医疗保健利用和生活质量产生巨大影响。虽然许多精神卫生系统已经在实施EBPS的项目上投入了大量资金，但最近的研究揭示了这些治疗的长期可持续性和高质量提供方面的一些挑战。很少有符合条件的患者在常规护理环境中接受EBPS，临床医生似乎没有向他们的许多患者提供完整的治疗方案。新出现的证据表明，当CPT和其他EBP以低保真度提供时，临床结果会受到负面影响。临床医生已经确定了他们不提供EBP的许多原因，这些原因与EBP与患者或临床环境之间的匹配有关。到目前为止，缺乏关于如何最好地支持和维持高质量EBP交付的指导。虽然一些系统已经制定了政策和计划来支持组织层面的EBP实施，但对于如何解决临床医生已经确定的剩余障碍知之甚少。因此，确定改进和维持CPT和其他EBP交付的战略至关重要。在现有的文献中已经提出了两种相互竞争的策略。其中一个强调通过持续的咨询和保真度监测来忠于治疗方案。另一个重点是通过数据驱动的持续质量改进过程，对治疗或临床环境进行适当的适应，从而提高这些治疗的适合性和有效性。这两个项目都没有从对持续执行的影响方面进行评估。为了比较这些方法在关键的可持续性结果上的差异，并为促进可持续发展的战略提供一些第一批指导，我们建议在三个已经实施CPT的不同精神卫生系统中进行一项与精神卫生诊所(n=32)的整群随机试验。一批临床医生和临床经理将参加一年的保真度导向的咨询或一年的持续质量改进导向的协作学习。将检查患者水平的创伤后应激障碍症状变化、CPT的保真度和适应性、穿透性以及临床提供EBP的能力。还将收集调查和访谈数据，以调查对两个实施战略成功的多层面影响。这项研究将由一组在CPT实施、混合方法研究策略、质量改进和实施科学方面具有专长的调查人员进行，每个参与的精神卫生系统的利益相关者都会提供意见。它将对在精神健康和医疗保健系统和环境中支持持续提供循证医学计划具有广泛的影响。由此产生的产品有可能极大地改善努力，以确保持续的高质量实施和消费者获得EBPS。

 DESCRIPTION (provided by applicant): Large-scale implementation of evidence-based psychotherapies (EBPs) such as Cognitive Processing Therapy (CPT) for Post-traumatic Stress Disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems have invested heavily in programs to implement EBPs, recent research has revealed a number of challenges to long-term sustainability and high- quality provision of these treatments. Few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggest that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Clinicians have identified a number of reasons that they do not deliver EBPs that are related to the fit between the EBP and their patients or the clinical setting. To date, there is a dearth of guidance on how best to support and sustain high-quality EBP delivery. While some systems have policies and programs in place to support EBP implementation at the organization level, little is known about how to address remaining barriers that have been identified by clinicians. Identifying strategies to improve and sustain the delivery of CPT and other EBPs is therefore critical. Two competing strategies have been suggested in the existing literature. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments by making appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation. To compare these approaches on key sustainability outcomes and provide some of the first guidance on strategies to promote sustainment, we propose a cluster randomized trial with mental health clinics (n=32) in three diverse mental health systems that have implemented CPT. Cohorts of clinicians and clinical managers will participate in one year of a fidelity oriented consultation or one year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, fidelity and adaptation of CPT, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two implementation strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed-methods research strategies, quality improvement, and implementation science, with input from stakeholders in each participating mental health system. It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.