Evaluation of the Caring Letters Suicide Prevention Intervention after Removal of an Electronic Health Record Flag for Suicide Risk: An Effectiveness-Implementation Hybrid Type 2 Trial

移除电子健康记录自杀风险标记后关怀信自杀预防干预的评估：有效性-实施混合 2 型试验

• 批准号: 10753299
• 负责人: Mark A. Reger
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-04-01 至 2026-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10753299
• 关键词: Acute; Address; Aftercare; Caring; Catchment Area; Clinical; Clinical Practice Guideline; Clinical effectiveness; Communication; Country; Data; Decentralization; Effectiveness; Effectiveness of Interventions; Electronic Health Record; Eligibility Determination; Emergency department visit; Evaluation; Excision; Follow-Up Studies; Frequencies; Goals; Healthcare; Hospitalization; Incidence; Individual; Intervention; Interview; Joints; Judgment; Leadership; Letters; Mental Health; Meta-Analysis; Modeling; Nature; Outcome; Outpatients; Patients; Personal Satisfaction; Persons; Policies; Population; Population Intervention; Prevention program; Procedures; Program Evaluation; Provider; Public Health; Randomized; Reporting; Resources; Risk; Schedule; Series; Structure; Suicide; Suicide attempt; Suicide prevention; Testing; Time; Veterans; Veterans Health Administration; Work; acute care; clinical implementation; cohort; design; effectiveness testing; effectiveness/implementation design; effectiveness/implementation hybrid; high risk; high risk population; hybrid type 2 trial; implementation barriers; implementation facilitators; implementation fidelity; implementation strategy; improved; informant; mortality; prevention service; preventive intervention; programs; protective effect; randomized, clinical trials; reducing suicide; response; secondary analysis; suicidal behavior; suicidal patient; suicidal risk; suicide mortality; suicide rate

ABSTRACT In the electronic health record (EHR), the Veterans Health Administration (VHA) uses patient record flags during periods of high acute risk for suicide (e.g., following a suicide attempt) to alert clinicians and improve suicide prevention services. Unfortunately, recent analyses revealed that after these high-risk flags (HRFs) are discontinued based on clinical judgement, suicide rates remain high in the year that follows. This creates a suicide prevention challenge. To address this need, VHA facilities were required in 2020 to start implementing the Caring Letters suicide prevention intervention for this population. In the Caring Letters intervention, a series of messages are sent to individuals to communicate that they are not forgotten, and that people care about them and are concerned for their well-being. The messages also serve as a reminder that help is available. Multiple randomized clinical trials support the efficacy of Caring Letters for reducing suicide behaviors in acute care settings. The Joint Commission recently promoted Caring Letters, and the intervention is included in the VA/DoD suicide prevention Clinical Practice Guideline for acute care settings. Unfortunately, the mandate to use this intervention with Veterans with a discontinued HRF (VD-HRF) has faced many challenges. Less than half the facilities across the nation have implemented the program. For facilities that have implemented the program, several concerning fidelity problems have been identified, indicating that thousands of Veterans in those catchment areas are not receiving the intervention as intended. Therefore, we propose a partnered program evaluation between the VHA Suicide Prevention Program (SPP), and the proposed evaluation team to examine a new version of the intervention for this unique population. Specifically, the evaluation will randomize all VA facilities to either: (1) Centralized Caring Letters where all the work of administering Caring Letters is centralized with a single, national team (promoting high fidelity and compliance with the requirement), or (2) De-Centralized Caring Letters in which VA facilities continue their local procedures as usual during a 6- month delay before starting Centralized Caring Letters. We will conduct an effectiveness-implementation Hybrid Type 2 trial. As a Hybrid Type 2 trial, the study has dual primary goals. The first is to test the effectiveness of a Caring Letter campaign for VD-HRFs, a relatively new population for the intervention. The second goal is to evaluate the impact of adding an implementation strategy – centralizing the work of Caring Letters – to the existing strategy of mandating change. The evaluation will test two aims. In Aim 1, we will evaluate the effects of Caring Letters on clinical outcomes and VA clinical utilization rates. An exploratory aim will also examine rates of suicide attempts, all-cause mortality, and suicide for Veterans who receive Centralized Caring Letters compared to a historical cohort who received no Caring Letters. In Aim 2, we will evaluate the impact of adding the implementation strategy of centralizing the work of the intervention to the existing implementation strategy of mandating change. Using qualitative interviews, we will evaluate leadership, staff, and provider perspectives on the implementation and sustainability of Centralized Caring Letters. This will be one of the largest evaluations of a Caring Letters intervention ever conducted, and it will provide direct and actionable data to leadership to evaluate the impacts of this major prevention program.

抽象的 在电子健康记录 (EHR) 中，退伍军人健康管理局 (VHA) 使用患者记录标记 在自杀风险较高的时期（例如，自杀未遂后），以发出警报并改善 不幸的是，最近的分析表明，在这些高风险标志（HRF）之后 根据临床判断，终止后的一年内自杀率仍然很高。 为了应对这一需求，VHA 设施需要在 2020 年开始实施。 关怀信件针对这一人群的自杀预防干预措施 在关怀信件干预措施中，有一系列的干预措施。 的消息被发送给个人，以传达他们没有被遗忘，并且人们关心 这些信息也提醒人们可以获得帮助。 多项随机临床试验支持关怀信对于减少急性自杀行为的功效 联合委员会最近推广了“关爱信”，并将干预措施纳入了“关爱信”。 VA/DoD 急性护理环境自杀预防临床实践指南不幸的是，该指令 对已停用 HRF (VD-HRF) 的退伍军人使用这种干预措施面临着许多挑战。 全国一半的设施已经实施了该计划。 计划中，已经发现了一些有关忠诚度的问题，这表明数以千计的退伍军人 这些流域没有得到预期的干预，因此，我们建议建立一个合作伙伴。 VHA 自杀预防计划 (SPP) 和拟议评估小组之间的计划评估 具体来说，评估将针对这一独特人群研究新版本的干预措施。 将所有 VA 设施随机分配为：(1) 集中关怀信，其中管理关怀的所有工作 信件集中在一个国家团队（促进高保真度和遵守要求）， (2) 去中心化关怀函，其中 VA 机构在 6-6 天内照常继续其当地程序 延迟一个月开始集中关怀信我们将进行一次有效性实施。 混合型 2 试验 作为混合型 2 型试验，该研究有两个主要目标：第一个是测试。 针对 VD-HRF 的关怀信活动的有效性，VD-HRF 是干预措施相对较新的人群。 第二个目标是评估添加实施策略的影响——集中关怀工作 信函——对现有战略的强制变革。在目标 1 中，我们将测试两个目标。 评估关怀信对临床结果和 VA 临床利用率的影响探索性目标。 还将检查接受治疗的退伍军人的自杀未遂率、全因死亡率和自杀率 与没有收到关怀信的历史群体相比，集中关怀信在目标 2 中，我们将。 评估将干预工作集中到实施战略中的影响 我们将使用定性访谈来评估现有的强制变革实施策略。 领导层、员工和提供者对集中关怀的实施和可持续性的看法 这将是有史以来对关爱信件干预措施进行的最大规模的评估之一，而且也将是这样的。 向领导层提供直接且可操作的数据，以评估这一重大预防计划的影响。