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Telephone Case Monitoring for Veterans with PTSD
Craig S. Rosen, PhD VA Palo Alto Health Care System, Palo Alto, CA Palo Alto, CA Funding Period: April 2006 - September 2011 Portfolio Assignment: Mental and Behavioral Health |
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BACKGROUND/RATIONALE:
Poor compliance with aftercare may contribute to high rates of relapse and rehospitalization among veterans who received residential treatment for posttraumatic stress disorder (PTSD). Telephone case monitoring has been shown to improve treatment adherence and reduced relapse among patients with chronic medical and substance use disorders, but has not been tested in PTSD patients. OBJECTIVE(S): This multisite randomized controlled trial tested whether augmenting usual aftercare with telephone monitoring improved resulted in 1) improved clinical outcomes (less violence, substance use, and PTSD symptoms; 2) longer time to rehospitalization; 3) better compliance with aftercare in the year after discharge from residential treatment for PTSD. METHODS: This trial recruited 837 subjects from 6 PTSD residential treatment programs at 5 VA medical centers, 94.7% of the 884 projected. Patients who completed at least 14 days of residential PTSD treatment and discharged to VA outpatient care were eligible to participate. Subjects were randomized to usual aftercare care (n = 425) or usual aftercare plus biweekly telephone case monitoring calls during the first three months after discharge (n = 412). Several factors contributed to our not meeting our planned enrollment target. Seventy-two subjects (not counted in the 837) were excluded after initial consenting because they later met exclusion criteria by discharging within 14 days of admission or discharging directly to another inpatient unit. One site had a higher than expected proportion of active duty patients who were ineligible to participate. Recruitment at two of the study sites was suspended for several months because they both had research stand-downs (unrelated to our study), which required establishing new Institutional Review Boards and re-approving all existing study protocols. Telephone case monitors assessed current problems, encouraged treatment adherence, provided problem-solving support, and alerted providers to emergent care needs. Patient self-report measures of psychiatric symptoms, substance use, and violence were obtained at intake to residential treatment and 4 months (69% completion rate) and 12 months (64% completion rate) after discharge. Retention was lower than our planned 70% to 75% rate due to difficulty locating some patients who moved (even their collateral informants did not know where they were) and 45 participants asking to discontinue due to lack of time (n = 10), general dissatisfaction with VA (n = 6), distress during phone calls (n = 5), dissatisfaction with compensation (n = 1), or no specified reason (n = 24). Treatment utilization data was obtained from the VA National Patient Care Database. Intent-to-treat analyses used mixed modeling to compare clinical outcomes in the telephone monitoring and usual care groups and 4 and 12 months after discharge. Survival analysis was used to compare conditions on time to rehospitalization. Having a smaller-than-intended sample size resulted in modest reductions in statistical power, e.g., power to detect the expected d = .25 effect on PTSD outcomes was reduced from about 90% to 82%, and power to detect the anticipated W = .105 difference in rehospitalization rates was reduced from 88% to 85%. Secondary analyses assessed whether differences in outcomes between the telephone case monitoring and usual care groups were mediated by attending more outpatient visits and completing more medication refills. Exploratory analyses examined whether the effect of telephone support on the clinical outcome measures, number of treatment visits, and medication refills was moderated by number of outpatient mental health visits in the prior year, distance from clinic, treatment expectancies, therapeutic alliance, or co-occurring substance use problems. FINDINGS/RESULTS: Telephone case monitors reached 86% of intervention participants (n = 355), and completed 4.5 out of 6 planned telephone calls. However, there were no significant differences in any clinical outcomes or in treatment utilization (number of mental health visits and medication refills) between patients in the telephone case monitoring and usual care conditions. Observed differences for all outcomes were small effects (d = -.09 to +.06) and as likely to favor usual care as the intervention. In contrast with prior studies reporting poor continuity of care in this population, participants in both arms of this study completed a mental health visit an average of every 10 days in the year after discharge. Many participants had continuing problems despite high utilization of outpatient care. IMPACT: Impact: Telephone care management had little incremental value in a context where patients were already high utilizers of mental health services. Telephone case monitoring may be more useful in other settings where patients currently receive less intensive services. External Links for this ProjectDimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Substance Use Disorders, Health Systems Science, Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial Keywords: Deployment Related, Operation Enduring Freedom, Operation Iraqi Freedom MeSH Terms: none |
