Anxiety diagnostic accuracy in VA primary care mental health integration settings: Identifying barriers and facilitators to inform a learning health care system

退伍军人事务部初级保健心理健康整合环境中的焦虑诊断准确性：识别障碍和促进因素，为学习型医疗保健系统提供信息

• 批准号: 10835851
• 负责人: Terri Lynn Fletcher
• 金额: --
• 依托单位: MICHAEL E DEBAKEY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-05-01 至 2022-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10835851
• 关键词: Academy; Address; Anxiety; Anxiety Disorders; Area; Attitude; Caring; Clinical Practice Guideline; Complex; DSM-V; Data; Diagnosis; Diagnostic; Diagnostic Errors; Diagnostic Specificity; Differential Diagnosis; Disease; Enrollment; Evidence based treatment; Exhibits; Funding; Generalized Anxiety Disorder; Goals; Health Personnel; Healthcare; Healthcare Systems; Intervention; Interview; Knowledge; Learning; Medicine; Mental Health; Mental Health Services; Methods; Mission; Morals; Panic Disorder; Patients; Phase; Positioning Attribute; Post-Traumatic Stress Disorders; Prevalence; Primary Care; Process; Provider; Psychiatric Diagnosis; Public Health; Qualitative Methods; Recommendation; Research; Services; Site; Social Anxiety Disorder; Symptoms; System; Testing; Training; Trauma; Veterans; accurate diagnosis; anxiety symptoms; behavioral health; clinical decision-making; clinically significant; contextual factors; data warehouse; design; diagnostic accuracy; diagnostic criteria; evidence base; health care quality; improved; integrated care; medical specialties; pharmacologic; psychologic; research and development; screening; treatment guidelines; workforce needs

Anticipated Impacts on Veteran's Healthcare: The provision of high quality healthcare requires accurate and timely diagnosis. The National Academy of Medicine asserts that “Improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.” Identifying factors influencing diagnostic accuracy is essential to improving the diagnostic process. The proposed study will identify factors associated with anxiety diagnostic errors in VHA primary care mental health integration (PCMHI) and specialty mental health (MH) settings, and addresses HSR&D priority areas "Mental and Behavioral Health” and “Health Care Systems Change” and the ORD-wide priority area “Learning Health Care System” Project Background: VHA has little information about specific determinants of current anxiety diagnostic practices and the sociotechnical context in which diagnoses are made. Unspecified anxiety disorder is the most common anxiety-related diagnosis in VHA but is often a diagnostic error. In FY2017, 408,250 Veterans enrolled in the VHA carried an unspecified anxiety disorder diagnosis, and unspecified anxiety accounted for 70% of anxiety diagnoses in PCMHI that year. However, the majority of these diagnoses are erroneous as fewer than 3% of Veterans diagnosed with unspecified anxiety meet DSM-5 criteria for this disorder. Accurate diagnosis is foundational to evidence-based healthcare, and 77% of Veterans diagnosed with unspecified anxiety meet diagnostic criteria for a specific anxiety or trauma-related disorder (generalized anxiety disorder [GAD, 44%]; posttraumatic stress disorder [PTSD, 38%]; panic disorder, 20%; social anxiety disorder 20%). Diagnostic accuracy is critical to accessing appropriate services. Only 32% of Veterans with unspecified anxiety disorder received mental health services in the year following diagnosis, compared to Veterans diagnosed with GAD (60%), panic disorder (67%), and social anxiety disorder (88%). Thus, an erroneous diagnosis of unspecified anxiety disorder is a barrier to receipt of appropriate evidence-based care for specific disorders such as PTSD, GAD, and panic disorder. Project Objectives: The proposed, 3-year, multisite study will use mixed quantitative and qualitative methods, informed by the Safer Dx framework, to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in VHA PCMHI and specialty MH settings. Understanding how these factors interact in the anxiety diagnostic process is crucial to identifying point(s) in the diagnostic process at which to intervene. Project Methods: The aims of the proposed project will be achieved through three major activities that will be carried out using mixed, qualitative and quantitative, methods. Aim 1 will use administrative data from the Corporate Data Warehouse (CDW) to identify system-, provider-, and patient-level factors associated with anxiety diagnostic specificity in PCMHI and specialty MH settings. Aim 2 will consist of qualitative interviews with PCMHI and specialty MH providers to understand their perspectives on barriers and facilitators to anxiety diagnostic specificity. Aim 3 will identify barriers to anxiety diagnostic specificity in each phase of the diagnostic process outlined by the Safer Dx framework. This aim will be achieved through chart reviews and diagnostic interviews of patients diagnosed with unspecified anxiety disorder, as well as critical incident interviews with PCMHI and specialty MH providers. Next Steps: Findings from this study will position the research team to design and test a tailored intervention to facilitate mental health providers' accurate and timely diagnosis of anxiety- and trauma-related disorders for Veterans.

对退伍军人医疗保健的预期影响：提供高质量的医疗保健需要准确的信息 美国国家医学科学院断言，“改进诊断过程并不重要”。 这不仅是可能的，而且也是道德、专业和公共卫生方面的必要因素。” 诊断准确性对于改进诊断过程至关重要。 确定与 VHA 初级保健心理健康整合中焦虑诊断错误相关的因素 (PCMHI) 和专业心理健康 (MH) 设置，并解决 HSR&D 优先领域“心理和 行为健康”和“医疗保健系统变革”以及 ORD 范围内的优先领域“学习医疗保健” “系统” 项目背景：VHA 对当前焦虑诊断的具体决定因素的信息很少 未特指的焦虑症是一种实践和诊断的社会技术背景。 VHA 中最常见的焦虑相关诊断，但在 2017 财年，有 408,250 名退伍军人被诊断为错误。 参加 VHA 的患者患有未明确的焦虑症诊断，并且未明确的焦虑导致 当年 PCMHI 中 70% 的焦虑诊断然而，其中大多数诊断都是错误的。 被诊断患有不明焦虑症的退伍军人中，只有不到 3% 符合 DSM-5 针对这种疾病的准确标准。 诊断是循证医疗保健的基础，77% 的退伍军人被诊断患有未明确的疾病 焦虑症符合特定焦虑症或创伤相关障碍（广泛性焦虑症）的诊断标准 [GAD，44%]；创伤后应激障碍[PTSD，38%]；恐慌症，20%）； 诊断准确性对于获得适当的服务至关重要，只有 32% 的退伍军人拥有未明确的特征。 与退伍军人相比，焦虑症在诊断后一年内接受了心理健康服务 诊断为广泛性焦虑症（60%）、恐慌症（67%）和社交焦虑症（88%）。 未明确的焦虑症的诊断是接受适当的基于证据的特定护理的障碍 创伤后应激障碍 (PTSD)、广泛性焦虑症 (GAD) 和恐慌症等疾病。 项目目标：拟议的为期 3 年的多地点研究将使用混合定量和定性方法， 根据 Safer Dx 框架的信息，识别与以下因素相关的系统、提供者和患者层面的因素： VHA PCMHI 和专业 MH 环境中的焦虑诊断特异性 了解这些因素的影响。 焦虑诊断过程中的相互作用对于确定诊断过程中的点至关重要 干预了。 项目方法：拟议项目的目标将通过三项主要活动来实现 目标 1 将使用来自 公司数据仓库 (CDW)，用于识别与相关的系统、提供商和患者层面的因素 PCMHI 和专业 MH 环境中的焦虑诊断特异性目标 2 将包括定性访谈。 与 PCMHI 和专业 MH 提供者合作，了解他们对焦虑障碍和促进因素的看法 目标 3 将确定每个阶段焦虑诊断特异性的障碍。 Safer Dx 框架概述的诊断流程将通过图表审查和实现。 对诊断患有未明确的焦虑症以及危急事件的患者进行诊断访谈 采访 PCMHI 和专业 MH 提供者。 后续步骤：这项研究的结果将使研究团队能够设计和测试量身定制的干预措施 促进心理健康提供者准确及时地诊断焦虑和创伤相关疾病 退伍军人。