Evidence-based Psychotherapy Template Use Associated with Treatment Quality for Veterans with PTSD
An estimated 23% of returning Veterans who use VA healthcare services have been diagnosed with PTSD. VA treatment guidelines recommend evidence-based psychotherapies (EBPs) as effective, first-line interventions for PTSD. Thus, VA has engaged in the largest dissemination and implementation effort of EBPs in the country. Concurrent with EBP training and consultation, the use of EBP templated notes, which can help measure whether psychotherapy is delivered with fidelity to an evidence-based model, is an important part of ongoing quality of care. Moreover, as of October 2014, EBP templates were mandated for those using EBPs in VA facilities. This study measured the prevalence of EBP templated notes in VA, testing the hypothesis that template use would be associated with quality of care for Veterans with PTSD. Using VA data, investigators identified all VA patients who received an outpatient PTSD diagnosis at a mental health encounter in FY2015 (n=630,746). The primary outcome measure was the facility-wide percentage of patients who received at least one EBP template (embedded into progress notes in patients' electronic health records). Investigators also assessed independent variables including facility-level demographic characteristics and care quality indicators, i.e., specialty care and adequate psychotherapy.
- In adjusted models, facility-level EBP template use was associated with a greater proportion of PTSD-diagnosed patients treated in specialty clinics, greater facility-level rates of diagnostic assessment, and greater rates of psychotherapy adequacy (8 psychotherapy visits in 14 weeks).
- Overall, an average of 4% of Veterans with a PTSD diagnosis received at least one EBP template. Among Veterans receiving psychotherapy for PTSD, an average of 9% received an EBP template.
- Facility-level EBP template use varied by region. For example, VA facilities in the Midwest administered templates to a greater percentage of patients than facilities in the Northeast.
- VA facilities with a greater percentage of patients who were service-connected at 50% or higher administered EBP templates to a smaller proportion of Veterans diagnosed with PTSD.
- The overall reach of EBP template usage was low, indicating that greater efforts are needed to improve usage. Methods to improve uptake of EBP templates, particularly in places where reach is very low, will require further study.
- The rate of agreement between EBP template usage and actual EBP care is unknown, although EBP template usage is likely an underestimate of actual EBP care.
- Overall, 20% of VA facilities did not use templates, so it is unlikely that EBP templates are capturing all EBP usage.
Drs. Sripada and Bohnert are supported by HSR&D Career Development Awards. All authors are with HSR&D's Center for Clinical Management Research (CCMR) in Ann Arbor, MI.
Sripada R, Bohnert K, Ganoczy D, and Pfeiffer P. Documentation of Evidence-Based Psychotherapy and Care Quality for PTSD in the Department of Veterans Affairs. Administration and Policy in Mental Health. September 30, 2017; Epub ahead of print.