RESUMO
OBJECTIVE: The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI). SETTING: Community. PARTICIPANTS: Healthcare providers (n = 63) with 2 or more years' experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach. DESIGN: Participatory-based research design, using descriptive and intervention mapping approaches. RESULTS: Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change. CONCLUSION: Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice.
Assuntos
Lesões Encefálicas Traumáticas , Dor Crônica , Humanos , Participação dos Interessados , Dor Crônica/terapia , Saúde Mental , Lesões Encefálicas Traumáticas/complicaçõesRESUMO
OBJECTIVE: To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. SETTING: Community. PARTICIPANTS: Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. DESIGN: Descriptive, qualitative study. MAIN MEASURES: Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. RESULTS: Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. CONCLUSION: This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.
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Lesões Encefálicas Traumáticas , Dor Crônica , Humanos , Dor Crônica/terapia , Acessibilidade aos Serviços de Saúde , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/psicologia , Cuidadores/psicologia , Pesquisa QualitativaRESUMO
OBJECTIVE: Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported. SETTING: Community. PARTICIPANTS: Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021. DESIGN: Descriptive, qualitative study. MAIN MEASURES: Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective. RESULTS: For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types. CONCLUSION: This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care.
Assuntos
Lesões Encefálicas Traumáticas , Dor Crônica , Humanos , Dor Crônica/diagnóstico , Dor Crônica/etiologia , Dor Crônica/terapia , Pesquisa Qualitativa , Disparidades em Assistência à Saúde , Qualidade da Assistência à Saúde , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnósticoRESUMO
OBJECTIVE: To compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups. DESIGN: Qualitative descriptive study guided by an access to health care services conceptual framework. SETTING: Five Veterans Affairs (VA) polytrauma rehabilitation centers. PARTICIPANTS: SMVs (N=55, including 10 caregivers as proxies) ≥2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe). MAIN OUTCOME MEASURES: Barriers and facilitators accessing care. RESULTS: The main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Distance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services. CONCLUSIONS: Barriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability.
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Lesões Encefálicas Traumáticas , Militares , Veteranos , Humanos , Acessibilidade aos Serviços de Saúde , Pesquisa Qualitativa , Centros de Reabilitação , Lesões Encefálicas Traumáticas/reabilitaçãoRESUMO
OBJECTIVE: To describe the self-reported needs of family caregivers of service members and veterans (SMVs) who sustained a traumatic brain injury (TBI) and to identify predictors of the unmet family caregiver needs. SETTING: Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: Family caregivers of SMVs enrolled in the VA PRC TBI Model Systems (TBIMS) national database who were within their first 5 years post-TBI ( n = 427). DESIGN: Observational study. MAIN OUTCOME MEASURE: The Family Needs Questionnaire-Revised (FNQ-R) was completed by each SMV's designated caregiver. ANALYSES: Descriptive analyses were conducted on the FNQ-R responses at the item, domain, and total score levels. Unadjusted univariable and adjusted multivariable regression models were fitted to identify predictors of total unmet needs and unmet family need domains. RESULTS: FNQ-R item-level and domain-level descriptive results indicated that health information was the most frequently met need domain. In contrast, emotional and instrumental support domains were the least often met. On average, family caregivers reported that 59.2% of the 37 FNQ-R needs were met at the time of the follow-up assessment. Regression models indicated that both the number of SMV-perceived environmental barriers and whether the SMV received mental health treatment within the past year predicted the number of unmet FNQ-R needs. SMV-reported environmental barriers predicted increased unmet needs in all 6 family caregiver domains, and SMV mental health treatment in the past year predicted more unmet family caregiver emotional support, community support, and professional support needs. CONCLUSIONS: The current findings can be used to inform policy and programming for VA and Department of Defense to proactively address the specific needs of families and caregivers experienced in the first 5 years post-TBI.
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Lesões Encefálicas Traumáticas , Veteranos , Humanos , Lesões Encefálicas Traumáticas/reabilitação , Cuidadores/psicologia , Veteranos/psicologia , Inquéritos e Questionários , Centros de Reabilitação , Família/psicologiaRESUMO
BACKGROUND: A proactive approach to delivering care using virtual resources, while reducing in-person contact, is needed during the COVID-19 pandemic. OBJECTIVE: In the current study we describe pre- to post- COVID-19 pandemic onset related changes in electronic delivery of primary care. METHODS: A longitudinal, pre-post within-subjects design was used. Patient-aligned care team providers from one VA medical center, a primary care annex, and four affiliated community-based outpatient clinics completed both a baseline and follow up survey (N = 62) or the follow-up survey only (N = 85). The follow-up survey contained questions about COVID-19. RESULTS: The majority of providers (88%) reported they would continue virtual care once pandemic restrictions were lifted. Most (83%) felt prepared to transition to virtual care when pandemic restrictions began. Use of My HealtheVet, Telehealth, and mobile apps showed a significant increase (22.7%; 31.1%; 48.5%). Barriers to virtual care included (1) internet connectivity; (2) patients' lack of technology comfort and skills; and (3) technical issues. Main supports to provide virtual care to patients were (1) peers/ colleagues; (2) technology support through help desk; (3) equipment such as laptops and dual screens; (4) being able to use doximety and virtual care manager, and (5) training. CONCLUSIONS: Overall, provider-use and perceptions related to using virtual care improved over time. Providers adapted quickly to providing virtual care during COVID-19 and planned to provide virtual care long-term.
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COVID-19 , Telemedicina , Humanos , COVID-19/epidemiologia , Pandemias , Instituições de Assistência Ambulatorial , Atenção Primária à SaúdeRESUMO
BACKGROUND: The COVID-19 pandemic has been a catalyst for rapid uptake of virtual care through the use of virtual health resources (VHR). In the Department of Veterans Affairs (VA) Healthcare System, virtual care has been critical to maintaining healthcare access for patients during COVID-19. In the current study we describe primary care patient aligned care team (PACT) VHR use patterns within one VA medical center (i.e., hospital facility and five community-based outpatient clinics) pre- and post-COVID-19 onset. METHODS: VHR provider and patient use data from 106 individual PACTs were extracted monthly between September 2019 to September 2020. Data were extracted from VHA web-based project application and tracking databases. Using longitudinal data, mixed effect models were used to compare pre- and post-COVID onset slopes. RESULTS: Findings highlight an increase in patient users of secure messaging (SM) and telehealth. The rate of utilization among these patients increased for SM but not for telehealth visits or online prescription refill (RxRefill) use. Finally, VetLink Kiosk check ins that are done at in person visits, diminished abruptly after COVID-19 onset. CONCLUSIONS: These data provide a baseline of VHR use at the PACT level after the initial impact of the COVID-19 pandemic and can inform healthcare delivery changes within the VA systems over time. Moreover, this project produced a data extraction blueprint, that is the first of its kind to track VA VHR use leveraging secondary data sources.
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COVID-19 , United States Department of Veterans Affairs , Humanos , Estados Unidos/epidemiologia , COVID-19/epidemiologia , Pandemias , Acessibilidade aos Serviços de Saúde , Atenção Primária à SaúdeRESUMO
OBJECTIVE: To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI). DESIGN: Prospective observational cohort. SETTING: Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS: VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Satisfaction With Life Scale (SWLS). RESULTS: Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P<.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction. CONCLUSIONS: Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction.
Assuntos
Lesões Encefálicas Traumáticas/psicologia , Lesões Encefálicas Traumáticas/reabilitação , Satisfação Pessoal , Veteranos/psicologia , Adulto , Fatores Etários , Lesões Encefálicas Traumáticas/epidemiologia , Depressão/epidemiologia , Avaliação da Deficiência , Feminino , Nível de Saúde , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores Sexuais , Participação Social/psicologia , Fatores Socioeconômicos , Fatores de Tempo , Índices de Gravidade do Trauma , Estados Unidos , United States Department of Veterans AffairsRESUMO
BACKGROUND: Proactive integrated virtual healthcare resource (VHR) use can improve efficiency, maximize resource capacity for delivering optimal coordinated care and improve patient outcomes. Proactive integrated VHR use is vital for delivering high quality care. Our objectives were to identify proactive integrated VHR use among primary care teams, best practices and targeted implementation strategies to promote proactive integrated VHR use. METHODS: This is a mixed-method descriptive study. We employed a community-based participatory approach to collect data and the Consolidated Framework for Implementation Research to analyze and contextualize findings. A cross-sectional sample of primary care team members (n = 65) from a Department of Veterans Affairs medical center participated in focus groups, follow-up interviews (n = 16), and respond to self-report surveys. Operational subject matter experts (n = 15) participated in informant interviews. RESULTS: Survey data described current use and factors that influenced singular VHR use and were convergent with qualitative findings. Focus group and interview data described no evidence of proactive integrated VHR use. Differences and similarities were identified between both utilization groups, such as facilitators and barriers, recommendations, patient education and preferred implementation strategies. All groups reported issues around VHR availability knowledge and access and functionality. Participants identified the need for best practices that are specific to care tasks and performance measures. Expert informant interviews identified a list of VHR tools that could be proactively integrated across the healthcare continuum. CONCLUSIONS: Health systems are leveraging technologies to proactively integrate VHR to maximize information exchange, clinical decision support and patient engagement. VHR is critical during global pandemics, such as COVID-19, to maintain access to care coordination and delivery while abiding by public health recommendations. Though recent requirements for reducing contact create an intrinsic motivation, cultural change through education and best practices of proactive integrated use across the healthcare continuum is needed to create a culture of VHR super users.
Assuntos
COVID-19 , Estudos Transversais , Acessibilidade aos Serviços de Saúde , Humanos , Atenção Primária à Saúde , Pesquisa Qualitativa , SARS-CoV-2RESUMO
The Veteran's Health Administration (VHA) Home Based Primary Care (HBPC) program provides comprehensive in-home primary care services to elderly Veterans with complex chronic medical conditions. Nurses have prominent roles in HBPC including as program leaders, primary care providers and nurses who make home visits. Delivery of primary care services to patients in their homes can be challenging due to travel distances, difficult terrain, traffic, and adverse weather. Mapmaking with geographic information systems (GIS) can support optimization of resource utilization, travel efficiency, program capacity, and management during normal operations, and patient safety during disasters. This paper reports on the feasibility, acceptability and outcomes of an initiative to implement GIS mapmaking in VHA HBPC programs. A mixed method evaluation assessed extent of adoption and identified facilitators and barriers to uptake. Results indicate that GIS mapping in VHA HBPC is feasible and can increase effectiveness and efficiency of VHA HBPC nurses.
Assuntos
Sistemas de Informação Geográfica , Pessoal de Saúde/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade , Idoso , Doença Crônica/terapia , Estudos de Viabilidade , Feminino , Pessoal de Saúde/tendências , Humanos , Entrevistas como Assunto , Avaliação de Programas e Projetos de Saúde , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologiaRESUMO
OBJECTIVE: To characterize employment stability and identify predictive factors of employment stability in working-age individuals after moderate-to-severe traumatic brain injury (TBI) that may be clinically addressed. DESIGN: Longitudinal observational study of an inception cohort from the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) using data at years 1, 2, and 5 post-TBI. SETTING: Inpatient rehabilitation centers with telephone follow-up. PARTICIPANTS: Individuals enrolled in the TBIMS-NDB since 2001, aged 18-59, with employment data at 2 or more follow-up interviews at years 1, 2, and 5 (N=5683). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Employment stability, categorized using post-TBI employment data as no paid employment (53.25%), stably (27.20%), delayed (10.24%), or unstably (9.31%) employed. RESULTS: Multinomial regression analyses identified predictive factors of employment stability, including younger age, white race, less severe injuries, preinjury employment, higher annual earnings, male sex, higher education, transportation independence postinjury, and no anxiety or depression at 1 year post-TBI. CONCLUSIONS: Employment stability serves as an important measure of productivity post-TBI. Psychosocial, clinical, environmental, and demographic factors predict employment stability post-TBI. Notable predictors include transportation independence as well as the presence of anxiety and depression at year 1 post-TBI as potentially modifiable intervention targets.
Assuntos
Lesões Encefálicas Traumáticas/reabilitação , Emprego/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Centros de Reabilitação , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: To examine incidence and predictors of employment stability in veterans and military service members with traumatic brain injury (TBI) who return to work. DESIGN: Prospective observational cohort study. SETTING: Four rehabilitation centers. PARTICIPANTS: Veterans and military service members (N=110) with mild (26%), moderate (22%), or severe (52%) TBI enrolled in the Department of Veterans Affairs Polytrauma Rehabilitation Centers TBI Model Systems database within 2 years of injury who were discharged between January 2009 and June 2015. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Employment stability as reflected by competitive employment at 1- and/or 2-year follow-up. RESULTS: Over half (n=61, 55%) of the participants had stable employment at the time the first competitive employment date was recorded. Individuals with stable employment were more likely to be white (79%) and to have slightly higher cognitive and motor discharge scores on the FIM. Based on univariate analysis, more severe TBI and higher FIM motor scores at discharge were significantly associated with employment stability. At follow-up, compared with veterans and military service members who had unstable employment, those with stable employment had higher scores on motor and cognitive FIM and lower scores of self-report symptoms on the Neurobehavioral Symptom Inventory, the 9-item Patient Health Questionnaire-Depression, the 7-item Generalized Anxiety Disorder Questionnaire, and the PTSD Checklist-Civilian version. CONCLUSIONS: A number of unique factors affect employment stability in veterans and military service members with TBI. Study findings identify veterans and military service members who have stable employment and predictors of employment stability.
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Lesões Encefálicas Traumáticas/psicologia , Emprego/psicologia , Militares/psicologia , Veteranos/psicologia , Lesões Relacionadas à Guerra/psicologia , Adulto , Lesões Encefálicas Traumáticas/reabilitação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Centros de Reabilitação , Retorno ao Trabalho/psicologia , Fatores de Tempo , Estados Unidos , United States Department of Veterans Affairs , Lesões Relacionadas à Guerra/reabilitaçãoRESUMO
BACKGROUND: The Department of Veterans Affairs (VA) has multiple health information technology (HIT) resources for veterans to support their health care management. These include a patient portal, VetLink Kiosks, mobile apps, and telehealth services. The veteran patient population has a variety of needs and preferences that can inform current VA HIT redesign efforts to meet consumer needs. OBJECTIVE: This study aimed to describe veterans' experiences using the current VA HIT and identify their vision for the future of an integrated VA HIT system. METHODS: Two rounds of focus group interviews were conducted with a single cohort of 47 veterans and one female caregiver recruited from Bedford, Massachusetts, and Tampa, Florida. Focus group interviews included simulation modeling activities and a self-administered survey. This study also used an expert panel group to provide data and input throughout the study process. High-fidelity, interactive simulations were created and used to facilitate collection of qualitative data. The simulations were developed based on system requirements, data collected through operational efforts, and participants' reported preferences for using VA HIT. Pairwise comparison activities of HIT resources were conducted with both focus groups and the expert panel. Rapid iterative content analysis was used to analyze qualitative data. Descriptive statistics summarized quantitative data. RESULTS: Data themes included (1) current use of VA HIT, (2) non-VA HIT use, and (3) preferences for future use of VA HIT. Data indicated that, although the Secure Messaging feature was often preferred, a full range of HIT options are needed. These data were then used to develop veteran-driven simulations that illustrate user needs and expectations when using a HIT system and services to access VA health care services. CONCLUSIONS: Patient participant redesign processes present critical opportunities for creating a human-centered design. Veterans value virtual health care options and prefer standardized, integrated, and synchronized user-friendly interface designs.
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Grupos Focais/métodos , Informática Médica/métodos , Telemedicina/métodos , United States Department of Veterans Affairs , Veteranos/psicologia , Estudos de Coortes , Feminino , Humanos , Masculino , Participação do Paciente , Estados UnidosRESUMO
BACKGROUND: Return to work is associated with positive rehabilitation outcomes for persons with spinal cord injury (SCI); however, more research is needed on vocational support for persons with disabilities seeking employment. OBJECTIVE: The association between facilitators and barriers of employment and employment outcome was examined among Veterans with SCI who participated in an evidence-based supported employment (EBSE) program. METHODS: Using a mixed-methods, nested case-control design, data on facilitators and barriers to employment were extracted from qualitative interviews and quantitative measures administered in person to 34 Veterans with SCI who completed 12 months of an EBSE program. Participants who did (case) and did not (control) obtain competitive employment were matched on time since SCI. Facilitators and barriers to employment were compared between the groups. RESULTS: Self-report measures administered at baseline were examined; there were no statistically significant factors that predicted employment outcomes after 12 months of EBSE program participation. Qualitative interview data revealed program-specific facilitators and Veteran characteristics that were associated with employment outcomes. CONCLUSIONS: Qualitative data illustrate how the integration of the vocational rehabilitation specialist on the medical team is helpful for addressing identified disability-specific barriers, including practical matters such as transportation and caregiving schedules, to facilitate employment outcomes.
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Emprego , Traumatismos da Medula Espinal/reabilitação , Veteranos , Adulto , Acessibilidade Arquitetônica , Estudos de Casos e Controles , Computadores , Depressão/complicações , Avaliação da Deficiência , Escolaridade , Emprego/psicologia , Readaptação ao Emprego/organização & administração , Prática Clínica Baseada em Evidências , Fadiga/complicações , Feminino , Nível de Saúde , Humanos , Seguro por Deficiência/economia , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Motivação , Equipe de Assistência ao Paciente/organização & administração , Qualidade de Vida , Tecnologia Assistiva , Traumatismos da Medula Espinal/complicações , Inquéritos e Questionários , Meios de TransporteRESUMO
BACKGROUND: Spinal cord injury is a condition that adversely impacts employment and economic stability. The Kessler Foundation National Employment and Disability Survey (KFNEDS) was developed to understand the experience of striving to work among persons with disabilities. However, this survey was not intended to capture the employment experiences of veterans living with spinal cord injury. The aim of this study was to engage veterans living with a spinal cord injury to adapt the KFNEDS for veterans living with this specific disability. OBJECTIVES: Describe the process and outcomes of actively engaging veterans living with spinal cord injury in the revision of the KFNEDS. METHODS: In this multiphase qualitative study, we used an iterative veteran-centered approach to engage veterans living with an SCI in all project phases. We consulted with a Veterans' hospital's Veteran Engagement Group and convened a study-specific Community Action Board to engage in a collaborative partnership with the research team. We recruited 17 veterans living with a spinal cord injury, employed or looking for employment since their spinal cord injury, to participate in focus groups and cognitive interviews that informed the adaptation of the KFNEDS-VS. RESULTS: A provisional version of the KFNEDS-VS included 37 survey questions in the following sections: Disability Screen, Employment Screen, Disability, Employment Overall, Looking for Work, At Work, and Workplace Accommodations and Supports. Revisions included wording changes for clarity, veteran and spinal cord injury-specific content that was missing from the questions or response options, and removal of irrelevant questions. CONCLUSIONS: Engaging veterans in multiple phases of the study lead to the development of a relevant survey that captures the lived experience of veterans seeking, obtaining, and maintaining employment following spinal cord injury.
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Pessoas com Deficiência , Readaptação ao Emprego , Traumatismos da Medula Espinal , Veteranos , Humanos , Veteranos/psicologia , Pesquisa Participativa Baseada na Comunidade , Pessoas com Deficiência/psicologiaRESUMO
PURPOSE: To describe the development of the Rehabilitation Needs Survey (RNS) for persons in the chronic phase of traumatic brain injury (TBI) recovery. MATERIALS AND METHODS: RNS items were generated following a literature review (January - March 2015) on the topic of rehabilitation needs and revised via consensus from an expert panel of TBI clinicians and researchers. The RNS was added to the VA TBI Model Systems longitudinal study; data collection occurred between 2015-2019. Needs were classified as current (if endorsed) or absent; if current, needs were classified as unmet if no help was received. Need frequency and association with rehabilitation outcomes were presented. RESULTS: Eight studies examined rehabilitation needs and formed the initial item pool of 42 needs. This was reduced to form the 21-item RNS which was administered at year 1 (n = 260) and year 2 (n = 297) post-TBI. Number of needs endorsed was 8-9, and number of unmet needs was 1-2, on average. Number of needs was correlated with functional status, neurobehavioral symptoms, and mental health symptoms (p < 0.05) suggesting support for convergent validity of the RNS. CONCLUSION: The RNS is a new measure of rehabilitation needs following TBI. Further investigation into its psychometrics and clinical utility is recommended.Implications for rehabilitationVeterans and Service Members with traumatic brain injury across the severity spectrum have ongoing rehabilitation needs during the chronic phase of recovery.The Rehabilitation Needs Survey is a standardized measure of rehabilitation needs following traumatic brain injury.Identification of unmet rehabilitation needs is important for raising awareness of service gaps and providing justification for resource allocation.
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Lesões Encefálicas Traumáticas , Militares , Veteranos , Lesões Encefálicas Traumáticas/reabilitação , Humanos , Estudos Longitudinais , Militares/psicologia , Psicometria , Inquéritos e Questionários , Veteranos/psicologiaRESUMO
OBJECTIVE: The purpose of this study was to describe incidence and assess predictors of adherence to Positive Airway Pressure (PAP) therapy for Obstructive Sleep Apnea (OSA) in persons with acquired brain injury (ABI). METHODS: A 2012-2015 retrospective analysis of consecutive ABI patients admitted for neurorehabilitation, referred for polysomnography (PSG), and prescribed PAP for OSA. Univariable linear regressions were conducted to examine predictors of average hours of nightly PAP use. Univariable logistic regressions were conducted to examine predictors of PAP adherence using the conventional clinical definition of ≥4 h per night ≥70% of the time. Persons with traumatic etiology were separately analyzed. RESULTS: ABI etiology was 51% traumatic, 36% stroke, and 13% other nontraumatic causes. Nearly two-thirds were nonadherent to PAP. For the overall sample, higher average nightly PAP usage was significantly predicted by positive hypertension diagnosis (ß = 0.271, p = 0.019). Likewise, greater adherence based on the conventional cutoff was predicted by poorer motor functioning at hospital admission (OR = 0.98, p = 0.001) and lower oxygen saturation nadir (OR = 0.99, p = 0.003). For those with traumatic injuries, greater adherence was predicted by poorer functional status at hospital admission (OR = 0.98, p = 0.010) and positive hypertension diagnosis (OR = 0.16, p = 0.023). CONCLUSIONS: In this study of hospitalized neurorehabilitation patients with ABI and comorbid OSA, predictors of adherence included lower oxygen saturation, poorer functional status and hypertension diagnosis, perhaps signifying the role of greater severity of illness on treatment adherence. High rates of refusal and nonadherence to frontline PAP therapy for sleep apnea is a concern for persons in recovery form ABI who are at a time of critical neural repair.
Assuntos
Lesões Encefálicas/reabilitação , Pressão Positiva Contínua nas Vias Aéreas , Pacientes Internados/estatística & dados numéricos , Apneia Obstrutiva do Sono/terapia , Cooperação e Adesão ao Tratamento/estatística & dados numéricos , Feminino , Humanos , Hipertensão/terapia , Incidência , Masculino , Pessoa de Meia-Idade , Desempenho Físico Funcional , Polissonografia , Estudos RetrospectivosRESUMO
PURPOSE/OBJECTIVE: To examine the influence of traumatic brain injury (TBI) severity on the health-related quality of life of caregivers providing care to service members/veterans (SMV) following a TBI. Research Method/Design: Thirty caregivers (90.0% female; 70.0% spouse; age: M = 39.5 years, SD = 10.7) of SMVs who sustained a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center and via community outreach to participate in one of six focus groups. Caregivers were classified into 3 TBI severity/caregiver groups: (a) moderate/severe/penetrating TBI caregiver group (n = 11); (b) mild TBI caregiver group (n = 10); and (c) equivocal TBI caregiver group (n = 9). Thematic analysis using a constant comparative approach was conducted with qualitative analysis software to identify common themes across the 3 severity/caregiver groups. RESULTS: Eleven themes emerged: no time for self/needs last (83.3%), poor physical health (80.0%), increased stress/anxiety (76.7%), social isolation/loneliness (66.7%), lack of access to services (50.0%), impact on family life (46.7%), sleep issues (46.7%), finances/employment (36.7%), depression (30.0%), exhaustion (30.0%), and anger (16.7%). Exploratory pairwise comparisons revealed a higher proportion of the moderate/severe/penetrating TBI group endorsed 7 of the 11 themes (no time for self/needs last, increased stress/anxiety, impact on family life, sleep issues, finances/employment, exhaustion, anger, and increased stress/anxiety) compared with the other 2 groups. CONCLUSIONS/IMPLICATIONS: It is important that caregivers of SMVs receive long-term support in their caregiving and parenting roles. Further work is required to understand the challenges caregivers experience in accessing services they need and how to effectively meet their needs across the care continuum. (PsycINFO Database Record (c) 2020 APA, all rights reserved).