The VA/DoD clinical practice guidelines for PTSD recommend the use of either selective serotonin reuptake inhibitors (SSRI) or serotonin norepinephrine reuptake inhibitors (SNRI) as first line pharmacotherapy for PTSD. In our prior HSR&D study of treatment participation among 7,645 Veterans recently diagnosed with PTSD, we found that the rate of SSRI/SNRI prescription rates were nearly twice as high among PTSD patients diagnosed in mental health clinics compared to those diagnosed in primary care (50% vs. 28%). Controlling for differences in demographics, access barriers, treatment need, treatment preferences and beliefs, Veterans diagnosed in primary care clinics received SSRI/SNRI prescriptions at one-half the rate of those Veterans diagnosed in mental health clinics, and any mental health care at less than one-third the rate. According to the Uniform Mental Health Services in VA Medical Centers and Clinics handbook issued by the Office of Mental Health and Suicide Prevention, mental health treatment, including pharmacotherapy, must be available in all primary care clinics. However, few CBOCs have a full time onsite mental health prescriber. The primary aim of this project is to increase the prescription rate of evidence based pharmacotherapy for PTSD by primary care providers in VA Community Based Outpatient Clinics (CBOCs).
1). Increase the proportion of Veterans diagnosed with PTSD in CBOCs who receive a guideline recommended medication from their primary care provider (PCP).
2). Increase the number of PCPs who prescribe guideline recommended medications for their PTSD patients.
3). Conduct a formative evaluation to refine the intervention and to identify barriers to and facilitators of its implementation.
We tested a multi-component clinical practice guideline implementation intervention in clusters of CBOCs associated with 3 different medical centers. 2 of the CBOC clusters were matched with 2 controls sites.
To increase PCP comfort with PTSD pharmacotherapy, the intervention provided online CME PTSD pharmacotherapy training in 2 30-minute courses, and eased access to PTSD guideline pharmacotherapy recommendations at the point-of-care by development and use of a CPRS-based PTSD pharmacotherapy decision support tool. The intervention also facilitated changes in PACT team and PCMHI processes of care regarding PTSD patients. The effectiveness of this multicomponent intervention was assessed using a clustered group randomized pre-post intervention design. A Formative Evaluation helped to refine the intervention, identified barriers to its implementation, and evaluated organizational and provider level factors that impacted intervention uptake.
Of PCPs in the intervention sites, 47% participated in at least one of the 2 CME PTSD pharmacotherapy training modules. Participation in PTSD pharmacotherapy trainings increased PCP comfort with treating PTSD. Factors identified as barriers to implementation included primary care appointment time pressures, discomfort with making PTSD diagnoses, and difficulty with being able to follow-up patients as recommended. Implementation facilitators included patient-centered orientation, patients reluctant to see MH providers or who live in rural areas, supportive and available PCMHI providers.
Although intent-to-treat analyses examining differences in rate changes between intervention and control sites were not significant, the subgroup of intervention arm PCPs who did the training showed a 36% increase in prescribing rates. Control arm PCPs and those in the intervention arm who did not do the training showed no appreciable changes in their prescribing rate. Additionally, patients whose PCP did the training were significantly more likely to receive appropriate follow-up care after receiving a prescription for a SSRI or SNRI by their PCP.
This project developed a CPRS-based PTSD pharmacotherapy Provider Decision Support tool and an online CME PTSD pharmacotherapy training course of 2 30-minute modules. Use of project tools increased the reach of PTSD pharmacotherapy to patients receiving primary care in CBOCs and improved their follow-up.
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