Hermes Eric D A, Rosenheck Robert A, Burrone Laura, Dante Greg, Lukens Carrie, Martino Steve
VA Connecticut Healthcare System, West Haven, CT.
Department of Psychiatry, Yale University School of Medicine.
Implement Res Pract. 2021 Nov 15;2:26334895211053659. doi: 10.1177/26334895211053659. eCollection 2021 Jan-Dec.
Digital interventions delivering Cognitive Behavioral Therapy for insomnia (Digital CBTi) may increase utilization of effective care for a common and serious condition. A low-intensity implementation strategy may facilitate digital CBTi use in healthcare settings. This pilot study assessed the feasibility of implementing a digital CBTi in Veterans Health Administration (VA) primary care through iterative modifications to a low-intensity implementation strategy, while evaluating clinical outcomes of a specific digital CBTi program.
A self-directed digital CBTi was implemented in the primary care clinics of a single VA facility using a cohort trial design that iteratively modified an implementation strategy over three 8-month phases. The phase 1 implementation strategy included (1) provider education; (2) point-of-care information via pamphlets; and (3) provider referral to digital CBTi through phone calls or messages. Phases 2 and 3 maintained these activities, while (1) adding a clinic-based coach who performed initial patient education and follow-up support contacts, (2) providing additional recruitment pathways, and (3) integrating the referral mechanism into provider workflow. Implementation outcomes included provider adoption, patient adoption, and acceptability. Clinical outcomes (insomnia severity, depression severity, and sedative hypnotic use) were compared among enrollees at baseline and 10 weeks.
Across all phases 66 providers (48.9%) made 153 referrals, representing 0.38% of unique clinic patients. Of referrals, 77 (50.3%) enrolled in the study, 45 (29.4%) engaged in the program, and 24 (15.7%) completed it. Provider and patient adoption did not differ meaningfully across phases. Among enrollees, digital CBTi was acceptable and the Insomnia Severity Index decreased by 4.3 points (t = 6.41, p < 0.001) and 13 (18.6%) reached remission. The mean number of weakly sedative-hypnotic doses decreased by 2.2 (35.5%) (t = 2.39, p < 0.02).
Digital CBTi implementation in VA primary care is feasible using low-intensity implementation strategy, resulting in improved clinical outcomes for users. However, iterative implementation strategy modifications did not improve adoption.The trial was registered at clinicaltrials.gov (NCT03151083).
提供失眠认知行为疗法的数字干预措施（数字CBTi）可能会增加对这种常见且严重疾病的有效治疗的利用率。低强度实施策略可能有助于在医疗机构中使用数字CBTi。这项试点研究通过对低强度实施策略进行迭代修改，评估了在退伍军人健康管理局（VA）初级保健中实施数字CBTi的可行性，同时评估了特定数字CBTi项目的临床结果。
在单个VA机构的初级保健诊所中实施了一项自我指导的数字CBTi，采用队列试验设计，在三个为期8个月的阶段中对实施策略进行迭代修改。第1阶段的实施策略包括：（1）提供者教育；（2）通过宣传册提供即时护理信息；（3）提供者通过电话或信息将患者转介至数字CBTi。第2阶段和第3阶段维持这些活动，同时：（1）增加一名驻诊教练，由其进行初始患者教育和后续支持联系；（2）提供更多招募途径；（3）将转诊机制整合到提供者工作流程中。实施结果包括提供者采用情况、患者采用情况和可接受性。在基线和10周时比较了入组者的临床结果（失眠严重程度、抑郁严重程度和镇静催眠药使用情况）。
在所有阶段，66名提供者（48.9%）进行了153次转诊，占诊所独特患者的0.38%。在转诊者中，77人（50.3%）参加了该研究，45人（29.4%）参与了该项目，24人（15.7%）完成了该项目。各阶段提供者和患者的采用情况没有显著差异。在入组者中，数字CBTi是可接受的，失眠严重程度指数下降了4.3分（t = 6.41，p < 0.001），13人（18.6%）达到缓解。镇静催眠药的平均每周使用剂量减少了2.2次（35.5%）（t = 2.39，p < 0.02）。
使用低强度实施策略在VA初级保健中实施数字CBTi是可行的，可为使用者带来改善的临床结果。然而，迭代实施策略修改并未提高采用率。该试验已在clinicaltrials.gov注册（NCT03151083）。
