Health Care Utilization of Veterans Receiving Supported Employment

接受支持性就业的退伍军人的医疗保健利用

• 批准号: 9396708
• 负责人: LORI L. DAVIS
• 金额: --
• 依托单位: TUSCALOOSA VETERANS AFFAIRS MEDICAL CTR
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-10-01 至 2019-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9396708
• 关键词: Accident and Emergency department; Accident and Emergency department; Acute; Acute; Affect; Affect; Afghanistan; Afghanistan; African American; African American; Age; Age; Area; Area; Assertiveness; Assertiveness; Behavioral; Behavioral; Caring; Caring; Characteristics; Characteristics; Clinical effectiveness; Clinical effectiveness; Collaborations; Collaborations; Computerized Patient Records; Computerized Patient Records; Cost Analysis; Cost Analysis; Cost Effectiveness Analysis; Cost Effectiveness Analysis; Cost Measures; Cost Measures; Costs and Benefits; Costs and Benefits; Decision Making; Decision Making; Diagnosis; Diagnosis; Diagnostic; Diagnostic; Emergency department visit; Emergency department visit; Employment; Employment; Enrollment; Enrollment; Evidence based intervention; Evidence based intervention; Female; Female; Future; Future; Geography; Geography; Gulf War; Gulf War; Health; Health; Healthcare; Healthcare; Healthcare Systems; Healthcare Systems; Homelessness; Homelessness; Income; Income; Individual; Individual; Inpatients; Inpatients; International; International; Intervention; Intervention; Investigation; Investigation; Investments; Investments; Iraq; Iraq; Leadership; Leadership; Learning; Learning; Length of Stay; Length of Stay; Life; Life; Link; Link; Medical Records; Medical Records; Mental Health; Mental Health; Mental disorders; Mental disorders; Methods; Methods; Modeling; Modeling; Occupations; Occupations; Outcome; Outcome; Outpatients; Outpatients; Patients; Patients; Pattern; Pattern; Persons; Persons; Policies; Policies; Population; Population; Post-Traumatic Stress Disorders; Post-Traumatic Stress Disorders; Poverty; Poverty; Primary Health Care; Primary Health Care; Productivity; Productivity; Quality of life; Quality of life; Randomized; Randomized; Randomized Clinical Trials; Randomized Clinical Trials; Randomized Controlled Trials; Randomized Controlled Trials; Recovery; Recovery; Research; Research; Research Personnel; Research Personnel; Resources; Resources; Risk; Risk; Services; Services; Supported Employment; Supported Employment; Symptoms; Symptoms; System; System; Therapeutic; Therapeutic; Time; Time; Unemployment; Unemployment; Veterans; Veterans; Visit; Visit; Vocational rehabilitation; Vocational rehabilitation; War; War; Work; Work; behavioral health intervention; behavioral health intervention; care systems; cohort; cohort; comparative; comparative; compare effectiveness; compare effectiveness; cooperative study; cooperative study; cost; cost; cost effective; cost effective; cost effectiveness; cost effectiveness; data archive; data archive; design; design; disability; disability; evidence base; evidence base; experience; experience; follow-up; follow-up; health care service utilization; health care service utilization; health service use; health service use; improved; improved; male; male; operation; operation; outpatient programs; person centered; person centered; programs; programs; prospective; prospective; secondary analysis; secondary analysis; self esteem; self esteem; service utilization; service utilization; severe mental illness; severe mental illness; stressor; stressor; working group; working group

Background: Iraq and Afghanistan war (OIF/OEF) Veterans have experienced repeated deployment- related stressors that put them at risk for health conditions that can negatively impact their post-deployment readjustment. Employment is a key indicator of successful reintegration, but OIF/OEF Veterans are less likely to be employed than their civilian counterparts, identifying difficulties at work and job loss as barriers to readjusting to civilian life. Additional challenges include psychiatric conditions, including posttraumatic stress disorder (PTSD), which is estimated to affect approximately 20% of OIF/OEF Veterans. Among the 5% costliest patients receiving VA care in fiscal year 2010, 17% had a PTSD diagnosis. Among these, their inpatient cumulative behavioral length of stay was 3.6 days, and outpatient utilization included 18.6 mental health visits, 1.8 emergency department visits, 6.5 primary care visits, and 5.2 subspecialty visits. Unemployment and service-connected disability in OIF/OEF Veterans has the potential to increase VA acute care service utilization, which may strain and have a long-term impact on VA resources, given that the OIF/OEF cohort will likely use VA services for six more decades. Interventions that assist Veterans in recovery and return to employment are expanding in the VA, but little is known about how these evidence- based interventions and subsequent return to work impacts the health service utilization patterns in unemployed Veterans with PTSD. This study seeks to gather this evidence to inform policy and practices in the delivery of the most effective vocational rehabilitation program for Veterans with PTSD. Methods: This study will evaluate the health service utilization among recently unemployed Veterans with a diagnosis of PTSD who have been randomized to receive either Individual Placement and Support (IPS) or Transitional Work (TW). IPS is an evidence-based model of supported employment, which is an assertive, person-centered, patient-driven approach to vocational rehabilitation. VA IPS has been available to Veterans with severe mental illness and to those who are homeless, but has not been accessible to Veterans with a primary diagnosis of PTSD. In 2013, under the leadership of Dr. Davis, VA Cooperative Studies Program (CSP) launched a multisite randomized controlled trial comparing the effectiveness of IPS to TWP for Veterans with PTSD (n=541) in terms of employment outcomes, PTSD symptoms, self-esteem and quality of life. This large, prospectively randomized, geographically diverse group of unemployed Veterans with PTSD represents a unique opportunity to learn more about the impacts of IPS on health care utilization. The specific aims of this study are to 1) compare the acute care utilization in Veterans with PTSD prospectively randomized to IPS versus TW; 2) compare the costs for high intensity services (i.e. inpatient, ED, domiciliary, residential) services and for outpatient services among Veterans with PTSD randomized to IPS versus TW; and 3) assess the cost-effectiveness of IPS relative to TW among Veterans with PTSD. Significance: Despite a decade of IPS implementation and a world-class medical record system within VA, no research has been conducted to evaluate the impact of IPS compared to TWP within VA on health care service utilization in a PTSD population. However, the strong evidence for reduction in acute care services among persons with serious mental illness randomized to IPS from US and international randomized clinical trials compels us to learn more about IPS in the VA setting and in a PTSD population. As more evidence emerges about the clinical effectiveness of IPS, stakeholders eagerly want to know if IPS has the potential to reduce the use of high intensity acute care services and potential cost effectiveness. This first-of-its-kind study is landmark given its timeliness, size (n=541), prospective randomized controlled design, VA setting, diagnostic focus (PTSD), use of computerized patient records from a fairly closed health care system (VA), comparative interventions (IPS/TW), and distinguished team of investigators.

背景：伊拉克和阿富汗战争（OIF/OEF）退伍军人经历了反复的部署 - 相关的压力源使他们面临可能对他们的遗嘱后部署产生负面影响的健康状况的风险 调整。就业是成功重新融合的关键指标，但OIF/OEF退伍军人少 可能比平民同行受雇，确定工作困难和失业是障碍 重新调整平民生活。其他挑战包括精神病，包括创伤后 应激障碍（PTSD），估计会影响约20％的OIF/OEF退伍军人。在 2010财政年度，有5％接受VA护理的最昂贵的患者有17％的PTSD诊断。其中，它们 住院累积行为长度为3.6天，门诊利用包括18.6心理 健康访问，1.8急诊室就诊，6.5次初级保健访问和5.2次专科访问。 OIF/OEF退伍军人的失业和与服务相关的残疾有可能增加VA 急性护理服务利用率，可能会对VA资源产生长期影响，鉴于 OIF/OEF队列可能会再使用VA服务了六十年。有助于退伍军人的干预措施 康复和恢复就业正在扩大，但对这些证据的方式知之甚少。 基于干预措施和随后的工作返回会影响卫生服务的利用模式 具有PTSD的失业退伍军人。这项研究旨在收集此证据，以告知政策和实践 通过PTSD为退伍军人提供最有效的职业康复计划。 方法：本研究将评估最近失业的退伍军人之间的卫生服务利用 诊断为随机接受个人安置和支持（IP）或 过渡工作（TW）。 IPS是一个基于证据的就业模型，这是一种自信， 以人为本的，以患者为中心的职业康复方法。 VA IP已可以使用 患有严重精神疾病和无家可归者但无法接触的退伍军人 具有PTSD的主要诊断的退伍军人。 2013年，在弗吉尼亚州戴维斯博士的领导下 研究计划（CSP）启动了比较IPS有效性的多站点随机对照试验 在就业结局，PTSD症状，自尊心方面，具有PTSD的退伍军人TWP 和生活质量。这个大型，前瞻性随机，地理上多样的失业组 具有PTSD的退伍军人代表了一个独特的机会，可以更多地了解IPS对医疗保健的影响 利用率。这项研究的具体目的是1）与PTSD比较退伍军人的急性护理利用率 前瞻性随机分配给IPS与TW； 2）比较高强度服务的成本（即住院医师 Ed，住宅服务的住所，以及随机的PTSD退伍军人的门诊服务 IPS与TW； 3）评估具有PTSD的退伍军人中IP相对于TW的成本效益。 意义：尽管IPS实施了十年和VA内的世界一流的医疗记录系统，但 与VA内的TWP对医疗保健相比，尚未进行评估IP的影响 PTSD人群中的服务利用。但是，急性护理服务减少的有力证据 在患有严重精神疾病的人中，来自我们的IP和国际随机临床 试验迫使我们在VA环境和PTSD人群中了解更多有关IP的信息。作为更多证据 关于IP的临床有效性的出现，利益相关者急切地想知道IPS是否有潜力 减少高强度急性护理服务和潜在的成本效益的使用。这首先 鉴于其及时性，大小（n = 541），前瞻性随机控制设计，VA设置， 诊断重点（PTSD），使用相当封闭的医疗保健系统（VA）的计算机化患者记录， 比较干预措施（IPS/TW）和杰出的调查人员团队。