Improving Care for Veterans by Understanding and Facilitating Transition to Recommended PTSD Treatment

背景：创伤后应激障碍(PTSD)是最常见的心理健康诊断之一 在退伍军人中。认知加工疗法(CPT)和长时间暴露疗法(PE)被广泛使用 在退伍军人健康管理局(VHA)作为推荐的创伤后应激障碍治疗进行传播。尽管如此 经过努力，很少有9/11事件后被诊断患有创伤后应激障碍的退伍军人启动CPT或PE。在退伍军人中的一小部分 接受这些治疗的人，CPT和PE很少是退伍军人接受的第一个治疗。一种常见的 实施研究中确定的治疗顺序，以“稳定治疗”组合开始 心理社会和药物治疗，使退伍军人为CPT或PE做好准备。现有研究中的一个空白是 治疗顺序，特别是稳定化治疗，如何影响CPT或PE的启动。 意义/影响：创伤后应激障碍是HSR&D的优先疾病，因为它在生物、心理和社会方面具有相当大的负面影响 对退伍军人生活的影响。需要新的策略来提高参与度、留存率和改进 建议的创伤后应激障碍治疗的结果，并减少在获得这种护理方面的差距。 了解如何最有效地结合和排序创伤后应激障碍的治疗是HSR&D确定的领域 兴趣，以及VHA创伤后应激障碍临床实践指南中发现的研究空白。 创新：尽管稳定治疗一直被认为是VHA的常见做法，但很少有研究 已经调查了这一治疗序列。解决创伤后应激障碍治疗中存在的局限性的新方法 交付涉及开发一种干预措施，既承认无处不在的存在，也承认 稳定治疗，同时促进从稳定治疗到CPT或PE的及时过渡。 具体目标：CDA-2旨在改善VHA中创伤后应激障碍服务的交付，同时 为我提供健康服务研究方法方面的培训，以支持我发展成为独立的 VHA研究员。提出的研究目标是：(1)定性地了解退伍军人和临床医生的 稳定化治疗的选择及稳定化治疗如何起到屏障作用的观点 向CPT或PE过渡的促进者；(2)开发和进行一项简短、实用的随机试点试验， 以退伍军人为中心的干预，支持从稳定治疗过渡到CPT或PE；以及(3) 确定治疗序列中的社会人口学差异，并确定治疗序列如何 影响VHA内CPT或PE启动的时间。 方法：然后，我将对全国退伍军人样本(n=30)进行定性访谈 临床医生(n=20；目标1)。使用快速定性分析程序，我将评估治疗序列如何， 特别是稳定化治疗，以及它们如何成为向CPT过渡的障碍或促进者 和体育课。然后，我将使用从目标1获得的知识来开发健康服务干预措施，以促进 及时过渡到CPT或PE。我将在一项随机、务实的试点试验中测试这种干预措施，比较 干预(n=20)至常规治疗(n=20；目标2)。我会评估退伍军人发起 CPT或PE在干预开始后一年内作为主要结果和作为次要结果的可行性 结果。使用来自9/11后退伍军人的全国性纵向队列的电子健康记录数据 10/05-12/23期间接受VHA创伤后应激障碍治疗(预计400,000人)，我将确定治疗顺序； 使用COX比例风险法了解治疗顺序如何影响CPT或PE开始的时间 回归；并根据社会人口学特征确定治疗序列中的差异(目标3)。 实施/下一步：我将把通过这项建议获得的知识和培训应用于 通过多站点大规模测试已开发干预措施的好处的HSR&D应用程序 第二类混合型实用试验。我将与心理健康办公室的组织伙伴合作 防止自杀，以确保工作支持促进临床实践指南一致的护理的努力。

Background: Posttraumatic stress disorder (PTSD) is one of the most common mental health diagnoses among Veterans. Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated in the Veterans Health Administration (VHA) as recommended PTSD treatments. Despite these efforts, few post-9/11 Veterans diagnosed with PTSD initiate CPT or PE. In the small percentage of Veterans who receive these therapies, CPT and PE are rarely the first treatment a Veteran receives. A common treatment sequence identified in implementation research, begins with “stabilization treatment,” combinations of psychosocial and medication treatments that prepare Veterans for CPT or PE. A gap in existing research is how treatment sequences, particularly stabilization treatment, influence initiation of CPT or PE. Significance/Impact: PTSD is an HSR&D priority condition due to its substantial negative biopsychosocial impact on Veterans lives. Novel strategies are needed to increase engagement, retention, and improve outcomes from recommended PTSD treatments, and to reduce disparities in access to this care. Understanding how to most effectively combine and sequence PTSD treatment is an HSR&D identified area of interest, and a research gap identified in the VHA PTSD clinical practice guideline. Innovation: Despite consistently identifying stabilization treatment as a common VHA practice, little research has investigated this treatment sequence. A novel approach to solving existing limitations in PTSD treatment delivery involves developing an intervention that both acknowledges the ubiquitous presence and benefits of stabilization treatment, while facilitating timely transition from stabilization treatment to CPT or PE. Specific Aims: This CDA-2 aims to improve delivery of PTSD services in the VHA, while simultaneously providing me with training in health services research methods to support my development into an independent VHA researcher. The proposed research aims are: (1) To qualitatively understand Veterans’ and clinicians’ perspectives on selecting stabilization treatments and how stabilization treatment serves as a barrier or facilitator of transition to CPT or PE; (2) To develop and conduct a randomized, pragmatic pilot trial of a brief, Veteran-centered intervention to support transition from stabilization treatment to CPT or PE; and (3) To identify sociodemographic disparities in treatment sequences and to determine how treatment sequences influence time to CPT or PE initiation across the VHA. Methodology: I will then conduct qualitative interviews with a national sample of Veterans (n=30) and clinicians (n=20; Aim 1). Using rapid qualitative analysis procedures, I will evaluate how treatment sequences, particularly stabilization treatment, are chosen and how they serve as a barrier or facilitator of transition to CPT and PE. I will then use knowledge gained from Aim 1 to develop a health services intervention that facilitates timely transition to CPT or PE. I will test this intervention in a randomized, pragmatic, pilot trial comparing the intervention (n=20) to treatment as usual (n=20; Aim 2). I will assess the proportion of Veterans who initiate CPT or PE within a year after beginning the intervention as a primary outcome and feasibility as a secondary outcome. Using electronic health record data from a national, longitudinal cohort of post-9/11 Veterans who received VHA PTSD treatment (anticipated n=400,000) from 10/05-12/23, I will identify treatment sequences; understand how treatment sequence impacts time to CPT or PE initiation using Cox proportional hazard regression; and identify disparities in treatment sequences based on sociodemographic characteristics (Aim 3). Implementation/Next Steps: I will apply the knowledge and training gained through this proposal to an HSR&D Merit application to test the benefits of the developed intervention on a large scale through a multisite hybrid type-II pragmatic trial. I will collaborate with organizational partners at the Office of Mental Health and Suicide Prevention to ensure that work supports efforts to promote clinical practice guideline-consistent care.