In this project we propose to conduct research that will allow us to examine the use of an academic detailing (AD) approach to share decision support tools with prescribing clinicians (providers) to decrease benzodiazepine prescribing in Veterans with PTSD. The AD approach supplements traditional AD outreach with facility-specific strategies that include development of solutions for local barriers. Our research group has conducted formative evaluation work that identified subgroups of Veterans with PTSD in which the prescribing of benzodiazepines has increased rates and the most potential for harm. It is possible the subgroups are also the ones who might have the most difficulty decreasing their benzodiazepine use, creating a burden on providers. Thus there is a need to focus educational efforts on these Veterans specifically that offer evidence- based options so they can make informed decisions for their care. We propose to address the following four specific research aims:
Aim 1 : Develop decision support tools and obtain input from providers and patients. Content for the decision support tools will initially be developed by a team of PTSD experts. Feedback from providers and patients will be obtained through individual qualitative interviews and incorporated at each step in the modification and development of final tools. The decision supports tools will provide general information about benzodiazepines; incorporate safety concerns related to the targeted subgroups, offer tapering guidance and information on safer, evidence-based treatments for PTSD.
Aim 2 : Use an enhanced academic detailing approach to beta test the decision support tools with providers. Using the VA Academic Detailing service in VISNs 21 & 22, we will obtain feedback on the effectiveness of the materials by providers and pharmacists assigned to work with the providers as detailers. Using data obtained through the VA Mental Health Dashboard we will identify providers with the highest caseload of Veterans with PTSD in the subgroups to participate in this research. The AD team will meet with the individual providers to review their caseload, review the decision support tools, and discuss motivational interviewing strategies to use with their patients, taking into account local context and needs. A facilitation checklist will be used to allow evaluation of the intervention and local adaptations needed.
Aim 3 : Conduct semi-structured interviews with providers and pharmacists to get their perspective on facilitators and barriers as to the use of the decision support tools with patients and the academic detailing program at their facility. To address this aim, we will conduct individual semi-structured qualitative interviews with the providers and pharmacists who participated in the Aim 2 intervention. Qualitative content analysis will be conducted on interview transcripts using previous methodology in our work.
Aim 4 : Collect limited facility and provider level quantitative outcomes that include changes in prescribing patterns and patient referrals to cognitive-behavioral therapy (CBT) from administrative data. To address this aim, we will use reports generated by the Mental Health Dashboard that will provide demographic data, changes in benzodiazepine prescribing patterns and other medication changes that might be reflected as substitutes for benzodiazepines. Referrals to PTSD evidence-based psychotherapy treatment will also be obtained by chart review.
This project seeks to develop decision support tools to be used by providers with patients and family members and will address a critical need identified in our previous work; information that supports providers and incorporates knowledge of patient preferences. We will conduct interviews with providers and Veterans and their family members to learn their perceptions about the materials and finalize the products. We will then pilot dissemination of the decision support tools using an academic detailing intervention. Through the use of an audit and feedback 'sustainability' tool, we will develop information on local factors that are critical as we plan for further dissemination and testing of the intervention to reduce inappropriate prescribing and increase appropriate care referrals for patients with PTSD.
