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RRP 11-432 – HSR Study

RRP 11-432
Examining the Implementation of Evidence-Based Psychotherapy for Veterans with PTSD
Bradley V Watts, MD MPH
White River Junction VA Medical Center, White River Junction, VT
White River Junction, VT
Funding Period: January 2012 - December 2012
Post traumatic stress disorder (PTSD) is a common and often debilitating condition in Veterans. Recent estimates suggest that a large percentage of Veterans returning from the wars in Iraq and Afghanistan suffer from PTSD. However, the largest group of Veterans currently presenting for PTSD treatment are Veterans who served during the Vietnam War era. Substantial numbers of Veterans from a range of eras are presenting to Veterans Health Administration (VHA) medical centers seeking treatment for PTSD.
Over the past twenty years, multiple specific treatments for PTSD have been developed. These treatments, including various types of both medications and psychotherapy, have shown effectiveness in rigorous clinical trials. Convergent recommendations suggest that medications (including selective serotonin reuptake inhibiters and noradrenergic antidepressants) and psychotherapies (including several forms of cognitive behavioral therapy) are effective treatments for PTSD.
VHA has advocated the use of several specific types of cognitive behavioral therapy to treat Veterans with PTSD. Evidence suggest that these therapies, including Prolonged Exposure (PE); 10 and Cognitive Processing Therapy (CPT); are well studied and highly efficacious in Veterans and can be implemented in routine practice. In addition to generally advocating the use of PE and CBT, VHA has taken steps to promote the implementation of these treatments. The Uniform Mental Health Services in VA Medical Centers and Clinics handbook requires that VA Medical Centers provide access to either (or both) of these treatments. In addition to providing supplementary funding for mental health staffing, VHA has an implementation program which provides specific training and mentorship for providers interested in learning about CBT and PE.
Multiple efforts have been aimed at gaining a better understanding of the use of evidence-based psychotherapies in VHA. The initial work in this area found considerable variation in the amount of psychotherapy provided at three VA facilities. Three subsequent studies examined the use of psychotherapy for PTSD using VHA national administrative data. They found that based on the number of visits no more than 10% of Veterans could have received adequate trials of the evidence-based psychotherapies for PTSD. Importantly, these studies may over estimate the amount of PE and CPT delivered to Veterans because they only counted the number of encounters and did not review individual patient records. Therefore, there is no current or reliable estimate of the amount PE and CPT done in VHA despite the efforts to spread the effective treatments nationally.

The overall goal of this pilot study is to examine the effectiveness of VHA efforts to promote use of PE and CPT to treat Veterans with PTSD. This pilot study will determine the use of PE and CPT in VISN 1 using a novel data extraction technique. Furthermore, we will explore factors at the VISN 1 medical centers that either facilitated or impeded the implementation efforts for these treatments. As this is a pilot project, we also aim to develop and refine our methods and plan a larger study to examine the same question in VHA nationally. Our specific objectives are to:
1) Determine the current use of Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) for the treatment of PTSD within the PTSD Clinical Teams (PCTs) in VISN 1.
2) Examine how contextual factors contributed to implementation of PE and CPT in VISN 1.
2a. Explore VISN 1 PCT providers' view of the evidence supporting the use of PE and CPT (research, clinical experience, patient experience, and local data).
2b. Explore VISN 1 PCT providers' view of their context (culture, leadership, and evaluation).
2c. Explore VISN 1 PCT providers' view of the facilitation activities of PE and CPT (purpose, role, and skills/attributes).
2d. Determine what factors (if any) are unique to the implementation of evidence-based psychotherapies. Attempt to map any newly identified factors onto the existing implementation frameworks and develop measures to account for these characteristics.

We have already identified patients new to outpatient PTSD Clinical Teams (PCT) who were receiving individual psychotherapy in VISN 1 during the first half of the 2010 fiscal year. These were patients who received an individual PCT stop code (540) associated with an individual psychotherapy administrative CPT code (90804, 90806, 90808, 90810, 90812, 90814, 90845, 90875, 90876, and 96152) and who had not received any PTSD care in the prior fiscal year. We obtained this data from the VISN 1 data warehouse and found that there were 1928 such patients. These patients were seen at one of the 6 outpatient PCT clinics in VISN 1.
Retrieval of Note Text: The Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) Informatics Group will pull relevant notes centrally using the data we obtained from the VISN 1 data warehouse for the twelve months following the initial PCT visit. MAVERIC has demonstrated an ability to access note text during our pilot studies, and we have developed a method to share the note text via a shared workspace on a secure research server located at the WRJ VAMC.
Automated Classification of PE and CPT Notes: In our previous pilot work we developed a coding algorithm to identify PE and CPT notes. We accomplished this through a process of manually coding notes to serve as a "gold standard" reference set (called annotation), and using ARC's "blast" feature to perform a series of iterative evaluations to determine the best algorithm for classifying note text (called machine learning). We will apply that best fit algorithm to the entire note set described above.
Validation: The manual raters will perform blind coding of 10% of the notes independently coded by NLP. If the kappa between the manual rating team and ARC is greater than 0.8, we will consider the automated ratings valid.
Determine Rates of PE and CPT Use: We will calculate the rate of PE and CPT use among new Veterans presenting to each of the six VISN 1 PCT clinics using our coded note set.

Review of administrative data revealed that 1,924 newly diagnosed patients with PTSD were seen at one of the New England VA specialty PTSD clinics in the first six months of 2010. The use of evidence-based psychotherapy for PTSD varied by site (see Table2). Overall there was greater variation in the use of CPT (from 1.5% to 13.1%) than in the use of PE (from none to 3.3%). The overall use of either of the evidence-based therapies for PTSD varied between sites from 3.7% to 13.5%. Patients who received any session of either therapy received a median of 5 sessions of the evidence-based therapy for PTSD. Again there was considerable variation between sites, ranging from 2 to 9 sessions.

Typically a full course of CPT in clinical trials was 12 sessions, and for PE a full course ranged from 8-18 sessions. While completing a full course may not be necessary in all cases, it is likely that less than five sessions of either treatment would not constitute an adequate dose of psychotherapy. Using a minimal threshold of 8 sessions suggests that 2.2% of newly presenting Veterans with PTSD received an adequate trial of either PE or CPT over their initial six months of care.

Next we correlated the proportion of patients receiving at least one session of evidence-based psychotherapy at each specialty PTSD clinic and the scores on each element of the PARIHS implementation framework using a Poisson linear regression. Five of the 18 elements showed a statistically significant association with use of at least one of the evidence-based psychotherapies for PTSD. The strongest predictor in terms of both the z-score of the association and the r2 of the correlation was a prior clinical experience and utilization EBT for PTSD. This suggests that attempts to use these treatments as part of training and other experiences strongly influences eventual adoption of the treatment. The next strongest predictor was a sustained involvement with the implementation team. Those sites with more sustained connection with the facilitation team were more likely to use EBT for PTSD. Similarly, if training was customized to the therapist, it was more likely that the therapy would be used clinically. Two elements were negatively correlated with use of EBT for PTSD. Contrary to the prediction of the conceptual framework, training focused on overall clinician development resulted in less use of EBT for PTSD than training that was narrowly focused on the use of the treatments. Lastly, organized and highly systematic mental health systems with clearly defined processes were slightly less likely to use EBT for PTSD. Again this finding was directionally opposite the prediction of our framework.

This project demonstrates the impact of VHA efforts to promote the use of evidence-based psychotherapy for PTSD. Furthermore, it provides important insights to the factors which are likely broadly important for implementation of any mental health practice. Lastly, the project shows the promise of natural language processing methodologies.

Future research could examine similar national trends in VA.

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None at this time.

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: none
MeSH Terms: none

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