Barriers and Potential Solutions to Implementing Evidence-Based PTSD Treatment in Military Treatment Facilities.

INTRODUCTION: Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers. MATERIALS AND METHODS: As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site. RESULTS: There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described. CONCLUSIONS: The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.

Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study.

BACKGROUND: Despite efforts by the U.S. Department of Defense to train behavioral health (BH) providers in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), numerous barriers limit EBP implementation. A context-tailored implementation approach called TACTICS (Targeted Assessment and Context-Tailored Implementation of Change Strategies) holds promise for increasing the use of EBPs such as prolonged exposure therapy (PE) in military treatment facilities. TACTICS combines a needs assessment, a rubric for selecting implementation strategies based on local barriers, an implementation toolkit, and external facilitation to support local champions and their implementation teams in enacting changes. This paper describes the rationale for and design of a study that will evaluate whether TACTICS can increase implementation of PE for PTSD and improve patient outcomes in military BH clinics relative to provider training in PE alone. METHODS: The study is a multi-site, cluster randomized, stepped-wedge trial, with the military treatment facility as the unit of analysis. Eight facilities undergo a provider-training phase, followed by 5 months of TACTICS implementation. The timing of TACTICS at each facility is randomly assigned to begin 9, 14, or 19 months after beginning the provider-training phase. Primary analyses will compare the proportion of PTSD patients receiving PE and patients' mean improvement in PTSD symptoms before and after the onset of TACTICS. DISCUSSION: TACTICS endeavors to balance standardization of empirically-supported implementation strategies with the flexibility of application necessary for success across varied clinical settings. If successful, TACTICS may represent a systematic and scalable method of promoting and supporting EBP implementation. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03663452.

Beck Depression Inventory-Fast Screen (BDI-FS): an efficient tool for depression screening in patients with end-stage renal disease.

Depression is common in patients suffering from end-stage renal disease (ESRD). Various screening tools for depression in ESRD patients are available. This study aimed to validate the Beck Depression Inventory-Fast Screen (BDI-FS) with the Beck Depression Inventory-II (BDI-II) as depression screening tool in conventional hemodialysis (CHD) patients. One hundred sixty two CHD patients were studied with both screening questionnaires. We used the Pearson Correlation Coefficient to measure the agreement between BDI-II and BDI-FS scores from 134 patients who responded to both questionnaires. Receiver operating characteristics curve and area under the curve were constructed to determine a valid BDI-FS cutoff score to identify ESRD patients at risk for depression. BDI-II and BDI-FS scores strongly correlated (Pearson r = 0.85, p < 0.0001). At a BDI-II cutoff ≥16, receiver operating characteristics showed the best balance between sensitivity and specificity for the BDI-FS cutoff value of ≥4 with a sensitivity of 97.2% (95% confidence interval [CI]: 85.5%, 99.9%) and a specificity of 91.8% (95% CI: 84.5%, 96.4%). When applying the above cutoff scores, prevalence of depressive symptoms in all completed questionnaires was found to be 28.7% (BDI-II) and 30.1% (BDI-FS), respectively. The BDI-FS was found to be an efficient and effective tool for depression screening in ESRD patients which can be easily implemented in routine dialysis care.

Thinking outside the box-identifying patients for home dialysis.

Home dialysis modalities are underutilized in the USA with only 8% of the dialysis patients undergoing renal replacement therapy at home versus 92% being treated with center hemodialysis. This is in contrast to the nephrology professionals' opinion about the best dialysis therapy and their potential choice in the hypothetical situation of choosing a dialysis modality for themselves. Pre-dialysis education changes the distribution of dialysis modality significantly, as 50% of informed patients choose home dialysis. Close collaboration among nephrology professionals, patients and providers is required to make home therapy a reality for any interested patient.

Perceptions about renal replacement therapy among nephrology professionals.

Usage of renal replacement modalities available for the treatment of end stage renal disease varies widely between countries, indicating that non-medical factors contribute to the choice of therapy. In the United States, 93% of the patients are treated with in-center hemodialysis (HD), about 7% undergo peritoneal dialysis (PD) and less than 1% are on home HD. In comparison, a Northern California-based nonprofit dialysis provider with home dialysis centers throughout the United States has achieved a home therapy penetration of 22%, the highest proportion of home therapies among U.S. dialysis providers. To better understand the perceptions about the various modality choices among caretakers (nephrologists and nurses) in this organization a short questionnaire was used. We examined the hypothetical setting of the caretakers being in the patient role. More than 90% of the nephrology professionals chose a home therapy as initial treatment option with close to equal distribution between PD and home HD. This pattern persisted for maintenance therapy with home HD being the preferred modality. Nephrologists' and nurses' perception of who makes modality decisions varied profoundly.