Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report.

Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.

Co-occurring implementation strategies: The effects of academic detailing for opioid use disorder campaign on the advancing pharmacological treatments for opioid use disorder (ADaPT-OUD) study.

Background: Barriers at the system, clinician, and patient level limit access to medications for opioid use disorder (MOUD). The Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy within the Veterans Health Administration (VHA) aimed at facility-level barriers to improve uptake of MOUD. During ADaPT-OUD, an independent Academic Detailing Services Opioid Agonist Treatment of OUD Campaign was co-occurring and aimed to increase evidence-based practice for OUD at the clinician level. While both these initiatives aim to increase MOUD reach, they address different barriers and did not intentionally collaborate. Thus, understanding the interaction between these two independent implementation initiatives and their effect on MOUD reach will further inform and mold future implementation efforts of MOUD. Methods: This was a secondary analysis of the ADaPT-OUD study that included 35 VHA facilities in the lowest quartile of MOUD reach; eight received the ADaPT-OUD external facilitation and 27 matched sites received implementation as usual. The number of academic detailing (AD) visits during ADaPT-OUD was used as a proxy for the intensity of Academic Detailing for OUD Campaign activity. The interaction between external facilitation status and AD intensity was evaluated by comparing the change in facility-level MOUD reach. Results: There was a general increase in the number of AD visits, in both external facilitation and implementation as usual sites, over the course of ADaPT-OUD's implementation period. A non-statistically significant, positively sloped, linear relationship was observed between average number of AD visits per quarter and change in MOUD reach in facilities also receiving ADaPT-OUD external facilitation that was not observed in the implementation as usual sites. Conclusion: Co-occurring initiatives focusing on different barriers to MOUD access have the potential to further increase MOUD in low-performing facilities, but further research into timing, quality, and collaboration between initiatives are warranted.

Medication treatment of opioid use disorder (MOUD) is a key element in addressing the opioid epidemic. The development, approval, and effectiveness of buprenorphine and naltrexone have expanded access to MOUD from specialty opioid treatment programs to office-based treatment. However, uptake of these evidence-based treatments across the Veterans Health Administration (VHA) is variable. To address this gap in care within the VHA, The Advancing Pharmacological Treatment for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy aimed at facility-level barriers at low-adopting VHA facilities while the VHA Pharmacy Benefits Management Academic Detailing Services Opioid Agonist Treatment of OUD Campaign implemented academic detailing with the goal to address clinician-level barriers. This article evaluates the effect these two co-occurring and independent initiatives had on each other and MOUD reach. The results suggest a trend toward a positive synergistic relationship between the two initiatives, that warrants further study and evaluation to inform further implementation efforts.

Adaptation in Young Military Recruits: Protocol for the Advancing Research on Mechanisms of Resilience (ARMOR) Prospective Longitudinal Study.

BACKGROUND: Military services provide a unique opportunity for studying resilience, a dynamic process of successful adaptation (ie, doing well in terms of functioning and symptoms) in response to significant adversity. Despite the tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding the neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential for enhancing the resilience of military service members. OBJECTIVE: The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize the trajectories of positive adaptation among young military recruits in response to basic combat training (BCT), a well-defined, uniform, and 10-week period of intense stress (aim 1), and identify promotive and protective processes contributing to individual variations in resilience (aim 2). The secondary objective is to investigate the pathways by which neurobehavioral markers of self-regulation assessed using electroencephalography and magnetic resonance imaging contribute to adaptive trajectories (aim 3). METHODS: ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped out for BCT. Participants (N=1201) are assessed at 5 time points over the initial >2 years of military service beginning before BCT (baseline) and followed up at 2 weeks and 6, 12, and 18 months after BCT. Participants complete web-based questionnaires assessing vulnerability and protective factors, mental health, and socioemotional functioning at each time point and a battery of neurocognitive tests at time 0. A subset of participants also complete structured diagnostic interviews and additional self-report measures and perform neurobehavioral tasks before and after BCT during electroencephalography sessions and before BCT only during magnetic resonance imaging sessions. RESULTS: This UG3/UH3 project was initially funded in August 2017, with the UG3 pilot work completed at the end of 2018. The UH3 phase of the project was funded in March 2019. Study enrollment for the UH3 phase began on April 14, 2019, and ended on October 16, 2021. A total of 1201 participants are enrolled in the study. Follow-up data collection for the UH3 phase is ongoing and projected to continue through February 2024. We will disseminate the findings through conferences, webinars, open access publications, and communications with participants and stakeholders. CONCLUSIONS: The ARMOR study provides a rich data set to identify the predictors and mechanisms of resilient and nonresilient outcomes in the context of military stressors, which are intended to empirically inform the development of prevention and intervention strategies to enhance the resilience of military trainees and potentially other young people facing significant life challenges. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51235.

Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder.

BACKGROUND: The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program. METHODS: We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data. RESULTS: The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages. CONCLUSIONS: Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.

Advancing Research on Mechanisms of Resilience (ARMOR) Prospective Longitudinal Study of Adaptation in Young Military Recruits: Protocol and rationale for methods and measures.

Background: Military service provides a unique opportunity for studying resilience, a dynamic process of successful adaptation (i.e., doing well in terms of functioning and symptoms) in response to significant adversity. Despite tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential to enhance the resilience of military service members. Objectives: The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize trajectories of positive adaptation among young military recruits in response to Basic Combat Training (BCT), a well-defined, uniform, 10-week period of intense stress (Aim 1) and identify promotive and protective processes contributing to individual variations in resilience (Aim 2). The secondary objective is to investigate pathways by which neurobehavioral markers of self-regulation assessed by electroencephalography (EEG) and magnetic resonance imaging (MRI) contribute to adaptive trajectories (Aim 3). Methods: ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped for BCT. Participants (N=1,201) are assessed at five timepoints over the initial 2+ years of military service beginning before BCT (baseline) and followed up at 2 weeks, 6, 12, and 18 months post-BCT. At each time point, participants complete online questionnaires assessing vulnerability and protective factors, mental health and social-emotional functioning, and, at Time 0 only, a battery of neurocognitive tests. A subset of participants also complete structured diagnostic interviews, additional self-report measures, and perform neurobehavioral tasks before and after BCT during EEG sessions, and, at pre-BCT only, during MRI sessions. Results: Study enrollment began April 14, 2019 and ended in October 16, 2021. A total of 1,201 participants are enrolled in the study (68.9% male; mean age = 18.9, SD = 3.0). Follow-up data-collection is ongoing and projected to continue through March 2024. We will disseminate findings through conferences, webinars, open access publications, and communications with participants and stakeholders. Conclusions: Results are expected to elucidate how young military recruits adapt to military stressors during the initial years of military service. Understanding positive adaptation of military recruits in the face of BCT has implications for developing prevention and intervention strategies to enhance resilience of military trainees and potentially other young people facing significant life challenges.

What Contributes to Sustainability? Examining Access to Medications for Opioid Use Disorder in Low-Adopting VHA Facilities.

BACKGROUND: Successful implementation can increase the availability of evidence-based treatments but continued patient access can be threatened if there is not deliberate focus on sustainment. Real-world examples are needed to elucidate contributors to sustainability. OBJECTIVE: We examined sustainability of outcomes of a study which tested a 12-month external facilitation intervention. The study evaluated change in access to medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) facilities in the lowest quartile of MOUD prescribing. DESIGN: Convergent mixed-methods design. PARTICIPANTS: Thirty-nine providers and leaders from eight VHA facilities. APPROACH: Thirty-minute post-implementation telephone interviews explored whether barriers identified pre-implementation were successfully addressed, the presence of any new challenges, helpfulness of external facilitation, and plans for sustaining MOUD access. Interviews were analyzed using a rapid turn-around approach. VHA administrative data were used to characterize the facilities and assess their ratio of patients with an OUD diagnosis receiving MOUD (MOUD/OUD ratio) at the end of a 9-month sustainability period. KEY RESULTS: Commonly reported contributors to sustained MOUD access included national attention on the opioid epidemic, accountability created by study participation, culture shift in MOUD acceptability, leadership support, and plans to build on initial progress. Frequently reported barriers included staffing issues and lack of MOUD-devoted time; the need to overhaul existing policies, practices, and/or processes; and fear and anxiety about MOUD prescribing. All facilities either maintained MOUD/OUD ratio improvement (n = 2) or further improved (n = 6) at the end of sustainability. Facilities with the highest and lowest ratio at the end of sustainability used a team-based approach to MOUD delivery; however, organizational setting differences may have impacted overall MOUD access. CONCLUSIONS: Ensuring stable and consistent staff, and sufficient time dedicated to MOUD are critical to sustaining access to evidence-based treatment in low-adopting facilities. This study highlights the importance of investing in local, system-level changes to improve and sustain access to effective treatments.

Impact of different cover letter information and incentives on Veterans' emotional responses to an unsolicited mailed survey about military traumas: a randomized, 3x2x2 factorial trial.

BACKGROUND: Altering cover letter information to reduce non-response bias in trauma research could inadvertently leave survey participants unprepared for potentially upsetting questions. In an unsolicited, mailed survey, we assessed participants' change in affect post-survey after altering key cover letter information and promising different incentives. We tested direct and indirect effects of participants carefully reading the cover letter on changes in their affect post-survey. METHODS: In a 3X2X2 randomized, factorial trial, 480 male and 480 female, nationally representative Veterans who were applying for posttraumatic stress disorder disability benefits were randomized to receive one of 12 different cover letters. The cover letters provided general versus more explicit information about the survey's trauma content and how their names were selected for study; we also promised different incentives for returning the survey. The main outcome was change in affect post-survey. We examined five potential moderators: combat or military sexual trauma exposure, posttraumatic stress disorder or serious mental illness diagnosis, and recency of military service. Mediators between reading the cover letter carefully and post-survey affect included how participants rated the cover letters' information and whether they thought the cover letters prepared them for the survey's content. A Bonferroni corrected alpha of 0.003 was the threshold for statistical significance. RESULTS: One hundred ninety men and 193 women reported their pre-and post-survey affect. Across all study conditions, out of 16 possible points, the net change in affect post-survey was less than a quarter-point for men and women. Mean changes in post-survey affect did not differ statistically significantly across any of the study factors (ps > 0.06); nor were there statistically significant interactions between any of the study factors and the 5 moderators after accounting for multiple comparisons (ps > 0.02). After controlling for pre-survey affect, reading the cover letter carefully had small effects on changes in post-survey affect, with larger associations seen in the women compared to men. Mediators' effects were often in opposite directions for men and women. CONCLUSION: General descriptions of a survey's trauma content appear ethically defensible. Research on cover letters' impacts on survey participants' emotional reactions and how those impacts differ by gender is needed.

Change in serum urate level with urate-lowering therapy initiation associates in the immediate term with patient-reported outcomes in people with gout.

OBJECTIVE: To examine the associations of changes in serum urate (SU) with health-related quality of life (HRQOL) in gout. METHODS: We used the first 6-months of data from four interventional trials and one observational, open-label study of urate-lowering therapy (ULT) use. HRQOL were assessed at baseline and every 3-months, and SU was measured monthly. Primary outcome measures were Short-form 36 physical and mental component summary scores, Health Assessment Questionnaire Disability Index (HAQ-DI), Sheehan Disability Scale (SDS), Patient Global Assessment, and pain scores in the last week. Linear mixed models for each outcome were adjusted as appropriate for current SU, change in urate in the last month, number of flare-affected days in the last month, baseline BMI, age, comorbidities, sex, ethnicity, trial/study and treatment combination, and tophi status (fixed effects); subject, and the trial/study month were random effects. RESULTS: Higher current SU correlated with reduced physical and mental HRQOL, and increased SDS and pain but not with HAQ-DI score. In the first 6-months of new/escalating ULT use, absolute change in SU levels associated with poorer outcomes on the HAQ-DI scale (ß (95% CI) = 0.013 (0.007-0.019)) and poorer outcomes on SDS, SF-36 MCS, patient global and pain scales. Reduction of SU associated with poorer outcomes in all six measures. CONCLUSION: High SU levels were associated with poorer HRQOL, pain and Sheehan disability score. Recent SU level fluctuations are associated with poorer outcomes, primarily driven by a reduction in SU. Clinical emphasis on slow rather than fast SU reduction and the routine use of effective, anti-inflammatory medications at ULT initiation/escalation may avoid short-term poor outcomes.

Impact of different cover letter content and incentives on non-response bias in a sample of Veterans applying for Department of Veterans Affairs disability benefits: a randomized, 3X2X2 factorial trial.

BACKGROUND: Non-random non-response bias in surveys requires time-consuming, complicated, post-survey analyses. Our goal was to see if modifying cover letter information would prevent non-random non-response bias altogether. Our secondary goal tested whether larger incentives would reduce non-response bias. METHODS: A mailed, survey of 480 male and 480 female, nationally representative, Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) Veterans applying for Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD). Cover letters conveyed different information about the survey's topics (combat, unwanted sexual attention, or lifetime and military experiences), how Veterans' names had been selected (list of OEF/OIF/OND Veterans or list of Veterans applying for disability benefits), and what incentive Veterans would receive ($20 or $40). The main outcome, non-response bias, measured differences between survey respondents' and sampling frame's characteristics on 8 administrative variables, including Veterans' receipt of VA disability benefits and exposure to combat or military sexual trauma. Analysis was intention to treat. We used ANOVA for factorial block-design, logistic, mixed-models to assess bias and multiple imputation and expectation-maximization algorithms to assess potential missing mechanisms (missing completely at random, missing at random, or not random) of two self-reported variables: combat and military sexual assault. RESULTS: Regardless of intervention, men with any VA disability benefits, women with PTSD disability benefits, and women with combat exposure were over-represented among respondents. Interventions explained 0.0 to 31.2% of men's variance and 0.6 to 30.5% of women's variance in combat non-response bias and 10.2 to 43.0% of men's variance and 0.4 to 31.9% of women's variance in military sexual trauma non-response bias. Non-random assumptions showed that men's self-reported combat exposure was overestimated by 19.0 to 28.8 percentage points and their self-reported military sexual assault exposure was underestimated by 14.2 to 28.4 percentage points compared to random missingness assumptions. Women's self-reported combat exposure was overestimated by 8.6 to 10.6 percentage points and military sexual assault exposure, by 1.2 to 6.9 percentage points. CONCLUSIONS: Our interventions reduced bias in some characteristics, leaving others unaffected or exacerbated. Regardless of topic, researchers are urged to present estimates that include all three assumptions of missingness.

Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD): an Implementation Trial in Eight Veterans Health Administration Facilities.

BACKGROUND: Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD. OBJECTIVE: Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls. DESIGN: Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention. PARTICIPANTS: VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block. INTERVENTION: External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation. MAIN MEASURES: Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities. KEY RESULTS: Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: - 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls. CONCLUSIONS: Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts.

Advancing Research on Mechanisms of Resilience (ARMOR) Longitudinal Cohort Study of New Military Recruits: Results from a Feasibility Pilot Study.

Psychological resilience as a longitudinal process is highly relevant for understanding the functioning outcomes of military populations. Here, we review the extant literature on resilience among military service members, focusing on National Guard Soldiers. Our specific project (Advancing Research on Mechanisms of Resilience, "ARMOR") aims to develop a comprehensive model of resilience using a multilevel perspective. We report results from our prospective pilot study (n = 103) conducted in preparation for our large-scale longitudinal cohort study of Basic Combat Training (BCT) and its impact on military recruits' wellbeing. Results support feasibility of the larger study, evidence for a new measure of BCT stressor exposure, and demonstrate preliminary associations with BCT-related stressors and longitudinal changes in adaptive functioning. Future directions for our larger study will utilize data from survey responses, structured clinical interviews, neurobehavioral tasks, and neurobiological measures (functional and structural MRI and electroencephalography [EEG]) to examine individual differences in self-regulation as a predictor of resilience-related processes. ARMOR is well positioned to elucidate mechanisms that could be targeted for promoting wellbeing, preventing psychopathology, and facilitating long-term recovery.

Reversals in initially denied Department of Veterans Affairs' PTSD disability claims after 17 years: a cohort study of gender differences.

BACKGROUND: In 2011, the Department of Veterans Affairs (VA) strengthened its disability claims processes for military sexual trauma, hoping to reduce gender differences in initial posttraumatic stress disorder (PTSD) disability awards. These process improvements should also have helped women reverse previously denied claims and, potentially, diminished gender discrepancies in appealed claims' outcomes. Our objectives were to examine gender differences in reversals of denied PTSD claims' outcomes after 2011, determine whether disability awards (also known as "service connection") for other disorders offset any PTSD gender discrepancy, and identify mediating confounders that could explain any persisting discrepancy. METHODS: From a nationally representative cohort created in 1998, we examined service connection outcomes in 253 men and 663 women whose initial PTSD claims were denied. The primary outcome was PTSD service connection as of August 24, 2016. Secondary outcomes were service connection for any disorder and total disability rating. The total disability rating determines the generosity of Veterans' benefits. RESULTS: 51.4% of men and 31.3% of women were service connected for PTSD by study's end (p < 0.001). At inception, 54.2% of men and 63.2% of women had any service connection-i.e., service connection for disorders other than PTSD (p = 0.01) and similar total disability ratings (p = 0.50). However, by study's end, more men than women had any service connection (88.5% versus 83.5%, p = 0.05), and men's mean total disability rating was substantially greater than women's (77.1 ± 26.2 versus 66.8 ± 30.7, p < 0.001). History of military sexual assault had the largest effect modification on men's versus women's odds of PTSD service connection. CONCLUSION: Even after 2011, cohort men were more likely than the women to reverse initially denied PTSD claims, and military sexual assault history accounted for much of this difference. Service connection for other disorders initially offset women's lower rate of PTSD service connection, but, ultimately, men's total disability ratings exceeded women's. Gender discrepancies in service connection should be monitored beyond the initial claims period.

Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration.

BACKGROUND: Despite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes. METHODS: Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes. RESULTS: Across eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4-12.4) and 9.9% increase (95% CI 3.6-16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16. CONCLUSIONS: Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.

Proactive tobacco treatment for veterans with posttraumatic stress disorder.

OBJECTIVE: Individuals with posttraumatic stress disorder (PTSD) smoke at higher rates compared to the general population and experience significant barriers to initiating cessation treatment. Proactive outreach addresses these barriers by directly engaging with smokers and facilitating access to treatment. The objective of the present study was to evaluate a proactive outreach intervention for increasing rates of treatment utilization and abstinence among veteran smokers with and without PTSD. METHOD: This is a secondary analysis of a randomized controlled trial conducted from 2013 to 2017 that demonstrated the effectiveness of proactive outreach among veterans using Veterans Affairs mental health care services. Electronic medical record data were used to identify participants with (n = 355) and without (n = 1,583) a diagnosis of PTSD. Logistic regressions modeled cessation treatment utilization (counseling, nicotine replacement therapy [NRT], and combination treatment) and abstinence (7-day point prevalence and 6-month prolonged at 6- and 12-month follow-ups) among participants randomized to proactive outreach versus usual care in the PTSD and non-PTSD subgroups, respectively. RESULTS: Compared to usual care, proactive outreach increased combined counseling and NRT utilization among participants with PTSD (odds ratio [OR] = 26.25, 95% confidence interval [3.43, 201.17]) and without PTSD (OR = 10.20, [5.21, 19.98]). Proactive outreach also increased 7-day point prevalence abstinence at 12 months among participants with PTSD (OR = 2.62, [1.16, 5.91]) and without PTSD (OR = 1.61, [1.11, 2.34]). CONCLUSIONS: Proactive outreach increased treatment utilization and abstinence among smokers with and without PTSD. Smokers with PTSD may need additional facilitation to initiate cessation treatment but are receptive when it is offered proactively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics.

To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .

A Theory of Planned Behavior Scale for Adherence to Trauma-Focused Posttraumatic Stress Disorder Treatments.

Evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy and prolonged exposure (CPT/PE), greatly reduce suffering for veterans, but many veterans fail to complete treatment. Developing a theory-based understanding of adherence is necessary to inform interventions to improve treatment retention. We developed and tested a series of scales applying the theory of planned behavior (TPB) to CPT/PE adherence. The scales were administered in mailed surveys as part of a larger mixed-methods study of veteran adherence to PE/CPT. Surveys were sent to 379 veterans who were initiating CPT/PE across four U.S. Veterans Affairs (VA) hospitals and 207 of their loved ones. Subsequent session attendance and homework compliance were coded via a review of electronic medical records. We examined item-level characteristics, factor structure, and the convergent and discriminant validity of the resultant scales. The findings support four subscales: two related to attitudes (i.e., Treatment Makes Sense and Treatment Fits Needs), one related to perceived behavioral control over participation (i.e., Participation Control), and one related to perceived family attitudes about CPT/PE participation (i.e., Subjective Norms). Scale validity was supported through significant associations with theoretically relevant constructs, including intentions to persist in CPT/PE, rs = .19-.38; treatment completion, rs = .21-.25; practical treatment barriers, rs = -.19 to -.24; and therapeutic alliance, rs = .39-.57.

Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids.

BACKGROUND: Long-term opioid therapy for chronic pain arose amid limited availability and awareness of other pain therapies. Although many complementary and integrative health (CIH) and nondrug therapies are effective for chronic pain, little is known about CIH/nondrug therapy use patterns among people prescribed opioid analgesics. OBJECTIVE: The objective of this study was to estimate patterns and predictors of self-reported CIH/nondrug therapy use for chronic pain within a representative national sample of US military veterans prescribed long-term opioids for chronic pain. RESEARCH DESIGN: National two-stage stratified random sample survey combined with electronic medical record data. Data were analyzed using logistic regressions and latent class analysis. SUBJECTS: US military veterans in Veterans Affairs (VA) primary care who received ≥6 months of opioid analgesics. MEASURES: Self-reported use of each of 10 CIH/nondrug therapies to treat or cope with chronic pain in the past year: meditation/mindfulness, relaxation, psychotherapy, yoga, t'ai chi, aerobic exercise, stretching/strengthening, acupuncture, chiropractic, massage; Brief Pain Inventory-Interference (BPI-I) scale as a measure of pain-related function. RESULTS: In total, 8891 (65%) of 13,660 invitees completed the questionnaire. Eighty percent of veterans reported past-year use of at least 1 nondrug therapy for pain. Younger age and female sex were associated with the use of most nondrug therapies. Higher pain interference was associated with lower use of exercise/movement therapies. Nondrug therapy use patterns reflected functional categories (psychological/behavioral, exercise/movement, manual). CONCLUSIONS: Use of CIH/nondrug therapies for pain was common among patients receiving long-term opioids. Future analyses will examine nondrug therapy use in relation to pain and quality of life outcomes over time.

The evaluating prescription opioid changes in veterans (EPOCH) study: Design, survey response, and baseline characteristics.

In the United States (US), long-term opioid therapy has been commonly prescribed for chronic pain. Since recognition of the opioid overdose epidemic, clinical practice guidelines have recommended tapering long-term opioids to reduced doses or discontinuation. The Effects of Prescription Opioid Changes for veterans (EPOCH) study is a national population-based prospective observational study of US Veterans Health Administration primary care patients designed to assess effects of evolving opioid prescribing practice on patients treated with long-term opioids for chronic pain. A stratified random sampling design was used to identify a survey sample from the target population of patients treated with opioid analgesics for ≥ 6 months. Demographic, diagnostic, visit, and pharmacy dispensing data were extracted from existing datasets. A 2016 mixed-mode mail and telephone survey collected patient-reported data, including the main patient-reported outcomes of pain-related function (Brief Pain Inventory interference; BPI-I scores 0-10, higher scores = worse) and health-related quality of life. Data on survey participants and non-participants were analyzed to assess potential nonresponse bias. Weights were used to account for design. Linear regression models were used to assess cross-sectional associations of opioid treatment with patient-reported measures. Of 14,160 patients contacted, 9253 (65.4%) completed the survey. Participants were older than non-participants (63.9 ± 10.6 vs. 59.6 ± 13.0 years). The mean number of bothersome pain locations was 6.8 (SE 0.04). Effectiveness of pain treatment and quality of pain care were rated fair or poor by 56.1% and 45.3%, respectively. The opioid daily dosage range was 1.6 to 1038.2 mg, with mean = 50.6 mg (SE 1.1) and median = 30.9 mg (IQR 40.7). Among the 73.2% of patients who did not receive long-acting opioids, the mean daily dosage was 30.4 mg (SE 0.6) and mean BPI-I was 6.4 (SE 00.4). Among patients who received long-acting opioids, the mean daily dosage was 106.2 mg (SE 2.8) and mean BPI-I was 6.8 (SE 0.07). Higher daily dosage was associated with worse pain-related function and quality of life among patients without long-acting opioids, but not among patients with long-acting opioids. Future analyses will use follow-up data to examine effects of opioid dose reduction and discontinuation on patient outcomes.

Effectiveness of Proactive Tobacco Cessation Treatment Outreach Among Smokers With Serious Mental Illness.

INTRODUCTION: People with serious mental illness (SMI) have a high smoking prevalence and low quit rates. Few cessation treatments are tested in smokers with SMI. Mental health (MH) providers are reluctant to address smoking. Proactive tobacco cessation treatment strategies reach out directly to smokers to offer counseling and medication and improve treatment utilization and quit rates. The current study is a secondary analysis of a randomized controlled trial of proactive outreach for tobacco cessation treatment in VA MH patients. AIMS AND METHODS: Participants (N = 1938, 83% male, mean age 55.7) across four recruitment sites, who were current smokers and had a MH visit in the past 12 months, were identified using the electronic medical record. Participants were randomized to Intervention (telephone outreach call plus invitation to engage in MH tailored telephone counseling and assistance obtaining nicotine replacement therapy) or Control (usual care). The current study assessed outcomes in participants with SMI (N = 982). RESULTS: Compared to the Control group, participants assigned to the Intervention group were more likely to engage in telephone counseling (22% vs. 3%) and use nicotine replacement therapy (51% vs. 41%). Participants in the Intervention group were more likely to be abstinent (7-day point prevalence; 18%) at 12 months than participants in the Control group (11%) but equally likely to make quit attempts. CONCLUSIONS: Proactive tobacco cessation treatment is an effective strategy for tobacco users with SMI. Proactive outreach had a particularly strong effect on counseling utilization. Future randomized clinical trials examining proactive tobacco treatment approaches in SMI treatment settings are needed. IMPLICATIONS: Few effective treatment models exist for smokers with SMI. Proactive tobacco cessation outreach with connections to MH tailored telephone counseling and medication promotes tobacco abstinence among smokers with SMI and is an effective treatment strategy for this underserved population.

Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial.

OBJECTIVE: Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy. DESIGN: Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120). METHODS: We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups. RESULTS: The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (ß = 0.058, P = 0.0002) and BPI severity (ß = 0.026, P = 0.0164). CONCLUSIONS: Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.