White River Junction VA Medical Center, VT 05009, USA.
National Center for PTSD Executive Division, VT 05009, USA.
Mil Med. 2021 Aug 28;186(9-10):e858-e866. doi: 10.1093/milmed/usaa389.
The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of EBP. Our objectives were to determine whether there is geographic variation in the initiation of EBP for PTSD in the VA and to identify patient and clinic factors associated with EBP initiation.
We identified VA patients with PTSD who had not received EBP as of January 2016 (N = 946,667) using retrospective electronic medical records data and determined whether they initiated EBP by December 2017. We illustrated geographic variation in EBP initiation using national and regional maps. Using multivariate logistic regression, we determined patient, regional, and nearest VA facility predictors of initiating treatment. This study was approved by the Veterans Institutional Review Board of Northern New England.
Nationally, 4.8% (n = 45,895) initiated EBP from 2016 to 2017, and there was geographic variation, ranging from none to almost 30% at the 3-digit ZIP code level. The strongest patient predictors of EBP initiation were the negative predictor of being older than 65 years (OR = 0.47; 95% CI, 0.45-0.49) and the positive predictor of reporting military-related sexual trauma (OR = 1.96; 95% CI, 1.90-2.03). The strongest regional predictors of EBP initiation were the negative predictor of living in the Northeast (OR = 0.89; 95% CI, 0.86-0.92) and the positive predictor of living in the Midwest (OR = 1.47; 95% CI, 1.44-1.51). The only nearest VA facility predictor of EBP initiation was the positive predictor of whether the facility was a VA Medical Center with a specialized PTSD clinic (OR = 1.23; 95% CI, 1.20-1.26).
Although less than 5% of VA patients with PTSD initiated EBP, there was regional variation. Patient factors, region of residence, and nearest VA facility characteristics were all associated with whether patients initiated EBP. Strengths of this study include the use of national longitudinal data, while weaknesses include the potential for misclassification of PTSD diagnoses as well as the potential for misidentification of EBP. Our work indicates geographic areas where access to EBP for PTSD may be poor and can help target work improving access. Future studies should also assess completion of EBP for PTSD and related symptomatic and functional outcomes across geographic areas.
美国退伍军人事务部（VA）在过去十年中一直致力于创伤后应激障碍（PTSD）的循证心理治疗（EBP）的实施，导致这些治疗方法在全国范围内的采用率缓慢但稳步上升。然而，以前的研究都没有调查 EBP 在 PTSD 中的起始的地理差异。我们的目的是确定 VA 中 PTSD 患者接受 EBP 的起始是否存在地理差异，并确定与 EBP 起始相关的患者和诊所因素。
我们使用回顾性电子病历数据确定了截至 2016 年 1 月尚未接受 EBP 的 PTSD 退伍军人（N=946667），并确定他们是否在 2017 年 12 月前开始接受 EBP。我们使用全国和地区地图说明了 EBP 起始的地理差异。使用多变量逻辑回归，我们确定了患者、地区和最近的 VA 设施启动治疗的预测因素。本研究得到了新英格兰北部退伍军人机构审查委员会的批准。
全国范围内，2016 年至 2017 年期间有 4.8%（n=45895）的人开始接受 EBP，并且存在地理差异，在 3 位邮政编码级别上的范围从没有到近 30%。EBP 起始的最强患者预测因素是年龄大于 65 岁的负预测因子（OR=0.47；95%CI，0.45-0.49）和报告与军事相关的性创伤的正预测因子（OR=1.96；95%CI，1.90-2.03）。EBP 起始的最强地区预测因素是居住在东北部的负预测因子（OR=0.89；95%CI，0.86-0.92）和居住在中西部的正预测因子（OR=1.47；95%CI，1.44-1.51）。EBP 起始的唯一最近 VA 设施预测因素是设施是否为设有专门 PTSD 诊所的 VA 医疗中心的正预测因子（OR=1.23；95%CI，1.20-1.26）。
尽管 PTSD 的 VA 患者中不到 5%的人开始接受 EBP，但存在地区差异。患者因素、居住地区和最近的 VA 设施特征都与患者是否开始接受 EBP 有关。本研究的优势包括使用全国性纵向数据，而劣势包括 PTSD 诊断的潜在误诊以及 EBP 的潜在误识别。我们的工作表明 PTSD 的 EBP 可能在某些地区难以获得，并有助于针对改善获取途径的工作。未来的研究还应评估 PTSD 中 EBP 的完成情况以及相关的症状和功能结果在地理区域的分布情况。
