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CDA 11-263 – HSR&D Study

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CDA 11-263
Improving Care for PTSD
Brian Shiner MD MPH
White River Junction VA Medical Center, White River Junction, VT
White River Junction, VT
Funding Period: July 2014 - June 2019

BACKGROUND/RATIONALE:
Posttraumatic stress disorder (PTSD) is an often chronic and disabling condition prevalent in the Veteran population. Evidence-based treatments, including medication and psychotherapy, can reduce or relieve the symptoms of PTSD and the disability associated with it. Over the last decade, the VA has funded development of new treatments, increased mental health staffing, and provided training to deliver evidence-based PTSD treatments.

However, there has been no comprehensive longitudinal analysis of the delivery of evidence-based treatments for PTSD over the initial decade of the VA's efforts to transform PTSD care. We do not know which national improvement strategies had the greatest effect on use of evidence-based treatments. We understand neither the relationship between specific implementation strategies and the uptake of specific treatments, nor how local context affects response to these improvement efforts. Furthermore, while access to mental health services has improved, there has been little evaluation of whether delivery of specific evidence-based treatments for PTSD has been timely. This information could help target efforts to improve the quality of VA PTSD care.

OBJECTIVE(S):
The broad objective of this 5-year career development program is to gain the education, mentorship, and research experience I need to launch a career as an independent investigator. My long-term goal is to improve the quality of VA PTSD care. To do this, I need to be able to measure quality, to understand what drives quality, and to design and test interventions to improve quality. My short-term goal is to develop skills in these areas.

My research objectives align with my short and long-term goals. I have developed a research plan that is focused on measuring longitudinal trends in the quality of VA PTSD care, understanding the effects of national improvement efforts, and performing exploratory analyses to begin to understand how facility-level factors, including patient population, settings and services, and improvement effort participation, drive quality. A merit review proposal, submitted in the third year, will be aimed at understanding the processes individual facilities follow to achieve their results in order to develop specific, testable interventions to improve PTSD care.

METHODS:
I will construct longitudinal measures of the use of evidence-based treatments for PTSD and the timeliness with which these treatments were delivered over the ten-year period starting in the 2004 fiscal year and ending in the 2013 fiscal year. I will use interrupted time series regression to determine how these trends relate to national implementation efforts. I will perform exploratory analyses using generalized liner mixed models to determine how these trends relate to facility-level factors.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This research will have a positive impact on the VA by determining which national improvement efforts have had the greatest effect on the uptake of evidence-based treatments for PTSD and the timeliness with which they are delivered. This work will also suggest possible improvements to strategies employed to measure use of evidence-based treatments for PTSD. Effectiveness and timeliness are two essential domains of the quality of PTSD care. A more accurate and comprehensive understanding these domains may improve VA efforts to implement high-quality mental health care more generally.

Year 1 Annual Report Update (July 2015): As described in the project timeline, year 1 research activities were limited to obtaining data and building the study dataset. As such, there have not been any findings that would alter the impact of this study.

Year 2 Annual Report Update (August 2016): Year 2 research activities primarily focused on developing methods to measure the provision of evidence-based care in individuals, so findings have not altered the impact of the study at this time. Analyses comparing receipt of these treatments among populations, including both longitudinal and facility-based cohorts, will be completed in Year 3 and may affect the impact of this study.

Year 3 Annual Report Update (August 2017): Year 3 research activities focused on finalization of methods to accurately measure receipt of evidence-based medications and psychotherapy for PTSD. Preliminary analyses using these measures will be completed and submitted as manuscripts for peer review this year. Thus findings affecting the impact of this work are likely to be published during Year 4.

Year 4 Annual Report Update (July 2018): Year 4 research activities focused classification of receipt of evidence-based medications and psychotherapy for PTSD. This facilitates the completion of work regarding quality (treatment adequacy) standards during Year 5. Planned manuscripts were partially completed during Year 4 and will be submitted during Year 5.

PUBLICATIONS:
None at this time.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Implementation
Keywords: none
MeSH Terms: none