RESUMEN
PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.
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Afecciones Crónicas Múltiples , Adulto , Humanos , Atención Primaria de SaludRESUMEN
BACKGROUND: Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration. METHODS: Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration. DISCUSSION: As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.
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Evaluación de Resultado en la Atención de Salud , Atención Primaria de Salud , Adulto , Costos de la Atención en Salud , Humanos , Atención Dirigida al Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto , Encuestas y CuestionariosRESUMEN
Given the upsurge of research in posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), much of which has focused on military samples who served in Iraq and Afghanistan, the purpose of this article is to review the literature published after September 11th, 2001 that addresses the epidemiology, pathophysiology, evaluation, and treatment of PTSD in the context of TBI.
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Lesiones Encefálicas/complicaciones , Personal Militar/estadística & datos numéricos , Trastornos por Estrés Postraumático/complicaciones , Encéfalo/patología , Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/epidemiología , Lesiones Encefálicas/terapia , Estudios de Cohortes , Diagnóstico Diferencial , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Humanos , Personal Militar/psicología , Neuroimagen/métodos , Evaluación de Resultado en la Atención de Salud/métodos , Trastornos por Estrés Postraumático/diagnóstico , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/terapiaRESUMEN
Suicide and suicide attempts are significant issues for military, Veterans Affairs (VA), and civilian healthcare systems. The lack of uniform terms related to self-directed violence (SDV) has inhibited epidemiological surveillance efforts, limited the generalizability of empirical studies of suicide and non-lethal forms of SDV, and complicated the implementation of evidence-based assessment and treatment strategies for individuals with suicidal thoughts and/or behaviors. The Department of Veterans Affairs recently adopted the Centers for Disease Control and Prevention's (CDC) SDV Classification System (SDVCS). This paper describes an implementation study of the SDVCS in two VA Medical Centers. The Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center (MIRECC) training program for the SDVCS, including the SDVCS Clinical Tool (CT), will be discussed. Although preliminary data suggest that the CT and SDVCS are generally perceived as being acceptable and useful, further work will likely be required to facilitate widespread adoption. Potential next steps in this process are presented.
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Conducta Autodestructiva/clasificación , Conducta Autodestructiva/psicología , Intento de Suicidio/clasificación , Intento de Suicidio/psicología , Suicidio/clasificación , Suicidio/psicología , Terminología como Asunto , Veteranos/psicología , Algoritmos , Conducta Cooperativa , Técnicas de Apoyo para la Decisión , Implementación de Plan de Salud/organización & administración , Hospitales de Veteranos/estadística & datos numéricos , Humanos , Capacitación en Servicio/organización & administración , Comunicación Interdisciplinaria , Determinación de la Personalidad/estadística & datos numéricos , Vigilancia de la Población , Servicio de Psiquiatría en Hospital/estadística & datos numéricos , Psicometría , Mejoramiento de la Calidad/organización & administración , Conducta Autodestructiva/epidemiología , Conducta Autodestructiva/prevención & control , Ideación Suicida , Suicidio/estadística & datos numéricos , Intento de Suicidio/estadística & datos numéricos , Estados Unidos , Veteranos/estadística & datos numéricos , Prevención del SuicidioRESUMEN
Surrogate endpoints frequently substitute for rare outcomes in research. The ability to learn about completed suicides by investigating more readily available and proximate outcomes, such as suicide attempts, has obvious appeal. However, concerns with surrogates from the statistical science perspective exist, and mounting evidence from psychometric, neurochemical, genetic, and neuroimaging studies suggests that surrogates may be particularly problematic in suicide research. The need for greater phenotypic refinement of suicide-related behaviors, development of and adherence to a shared suicide nomenclature, and conservative interpretation of investigational results that are limited to the precise population and suicide-related behavior under examination are discussed.
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Investigación Conductal , Biomarcadores , Suicidio , Investigación Conductal/métodos , Humanos , Suicidio/psicología , Suicidio/estadística & datos numéricos , Intento de Suicidio/psicología , Intento de Suicidio/estadística & datos numéricosRESUMEN
In this study, we investigated the Personality Assessment Inventory's (PAI; Morey, 1991, 2007) Suicide Potential Index (SPI) and Suicide Ideation scale (SUI) as predictors of suicidal behavior (SB) in military Veterans with traumatic brain injury (TBI; N = 154). We analyzed electronic medical records were searched for SB in the 2 years post-PAI administration and data via logistic regressions. We obtained statistical support for the SPI and SUI as predictors of SB. Analyses we performed using receiver operating characteristics suggested an optimal SPI cutoff of > or =15 for this sample. Findings suggest that SPI and SUI scores may assist in assessing suicide risk in those with TBI, particularly when population-based cutoffs are considered.