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2017 HSR&D/QUERI National Conference Abstract

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4032 — A Qualitative Study of Implementation and Adaptations to Progressive Tinnitus Management (PTM)

Lead/Presenter: Anais Tuepker, COIN - Portland
All Authors: Tuepker A (VA Portland Health Care System) Elnitsky C (University of North Carolina at Charlotte) Newell S (VA Portland Health Care System) Zaugg T (VA National Center for Rehabilitative Auditory Research (NCRAR)) Henry JA (VA National Center for Rehabilitative Auditory Research (NCRAR))

Military personnel are exposed to numerous hazards associated with tinnitus and hearing loss, with the result that tinnitus is the most prevalent service-connected disability among Veterans, affecting 1,450,462 Veterans in 2015. Progressive Tinnitus Management (PTM) is an interdisciplinary, structured, stepped-care approach to providing clinical services, including teaching coping skills, to people bothered by tinnitus. PTM has been shown to be effective at reducing functional distress, but implementation of the intervention outside of a research setting has not been studied, even though dissemination is underway within VA. This study was designed to identify factors facilitating or hindering implementation in VHA audiology and mental health clinic contexts, as well as intervention adaptations occurring at adopting sites.

Qualitative interviews were conducted with 21 audiology and mental health clinicians and service chiefs across VA's VISN 20 network. Interviews were transcribed and coded using a hybrid inductive-deductive analytic approach guided by existing implementation research frameworks and then iteratively developed for emergent themes.

PTM prioritization was rare overall, with providers across disciplines challenged by lack of capacity for implementation, but with differences by discipline in challenges to prioritization. Where PTM was prioritized and delivered, this was facilitated by perception of unique value, provider's own experience of tinnitus, observation/experience with PTM delivery, intervention fit with provider's skills, and an environment with supportive leadership and adaptive reserve. PTM was frequently adapted to local contexts to address delivery challenges and diversify patient options. Adaptations included shifting from group to individual formats, reducing or combining sessions, and employing novel therapeutic approaches.

Existing adaptations highlight the need to clarify mechanisms underlying PTM's effectiveness, and research on the impact of adaptations on patient outcomes is an important next step. Prioritization of PTM is a key barrier to the scale up and spread of this evidence-based intervention. Clinician champions facilitate dissemination, especially if accompanied by signals of systemic prioritization.

Novel approaches to expose clinicians and administrators to PTM may develop clinical champions. Acknowledging the potential for PTM adaptations may make delivery more feasible in contexts of existing system constraints.