Examination of Treatment Fidelity to Promote Quality of Care for PTSD
MHS Challenge Submission Examination of Treatment Fidelity to Promote Quality of Care for PTSD Dr. Jeffrey Greenberg Altarum Institute
It is well understood that psychological health problems such as posttraumatic stress disorder (PTSD) have been identified as one of the signature injuries of the current and recent conflicts in Afghanistan and Iraq. The nature of these conflicts (i.e. asymmetric/guerilla warfare tactics) indicates that military personnel will be at risk for exposure to trauma which serves as the genesis for development of PTSD. Furthermore, leaders such as former Chairman of the Joint Chiefs of Staff Admiral Mullen identified that meeting the needs of Service Members with war wounds was the most important goal of the Services outside of winning the war.
To that end, the responsible medical communities within the Department of Veterans Affairs (VA) and Department of Defense (DoD) have made a herculean effort at addressing the needs of military personnel diagnosed with psychological health problems. A principle strategy to meet this demand has been the identification of evidence based treatment models to treat disorders such as PTSD. Guideline supported models such as Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PET) have been identified as best practice treatments. Both therapies have a robust extant literature base supporting their use for individuals diagnosed with PTSD. Importantly, each model is supported by procedural manuals. That is, they are manualized treatments which provide step by step and session by session instructions for implementation. Notably, these treatments are effective when they are delivered with requisite fidelity. Fidelity is the construct, measurable as a statistically derived correlation coefficient, which denotes to what degree a treatment is delivered as intended. That these treatment models are “manualized” allows for analysis of fidelity to treatment delivery. Treatment manualization refers to a session by session guide to what is prescribed in a given treatment. This type of analysis supports two principle goals. First, it will inform leadership of the extent to which DoD clinical providers report use of evidence based treatment models for PTSD. Secondly, it will inform leadership of the degree to which providers are implementing treatments as intended. It will also provide an understanding of gaps in treatment fidelity and insights into performance improvement requirements. Understanding these constructs is essential to being able to identify the quality of care that Service Members receive.
Over the past decade, the Military Health System (MHS) has made access to care a significant priority. To meet this demand, a significant number of contract providers have been procured over the past decade. These providers have been added to the existing pool of uniform and civilian providers at military treatment facilities (MTF). While this effort supports the important goal of access to care, military leadership has very limited information on the quality of care provided (i.e. what treatments are being provided and are they being delivered appropriately).
I propose development of a fidelity analysis model for use in a pilot study. This effort would identify what treatments are reportedly implemented for individuals diagnosed with PTSD. Secondly, it would identify to what degree treatments are implemented as intended or level of fidelity. The literature supports the premise that delivering a treatment as prescribed is essential to achieving desired outcomes (e.g. symptoms reduction or remission).
Stage one of this study would entail use of a self-report instrument aimed at identifying treatments implemented for individuals with PTSD. Secondly, participating providers would tape sessions (with patient consent). Taping clinical psychotherapy sessions is common either as a teaching method or to enable clinician review of sessions. Taped sessions would be de-identified. The de-identified sessions would be reviewed by trained raters who would review content for adherence/non-adherence to session fidelity. The resultant Kappa analysis would offer military leaders insight into the effectiveness of care delivered and the efficiency of funds allocated for treatment.
Why does fidelity matter? There are a number of differences between psychological health interventions (i.e. psychotherapy) and physical interventions. For example, a person diagnosed with PTSD would benefit most from exposure based psychotherapy such as CPT or PET. The literature robustly supports this. Despite this, there is no guarantee that a patient with PTSD will be treated with an evidence based treatment model. Further, in cases where a provider purports to deliver evidence based psychotherapy, there is no guarantee it is delivered as intended. There are a number of reasons for this (e.g. patient in crisis or other difficulty adhering to a treatment); however fidelity to treatment is essential to delivering quality care. A prime model for calculating fidelity (Cohen’s’ Kappa inter-rater reliability analysis) indicates that fidelity should be met at .80 or higher
Moreover, there are notable differences between provider types. Psychological health interventions may be delivered by psychiatrists, psychologists, social workers and various types of counselors. Level of skill and training may vary widely. Further, specialization levels may vary. For example, a psychologist specially trained in treating disorders such as PTSD may not be qualified to treat an eating disorder. This variability contributes to potential differences in treatments received. Thus, treatment is not treatment is not treatment. A Service Member seeking care for PTSD may be treated by highly qualified individuals with specialized training in military medicine and PTSD, or they may not. This presents unique challenges to the MHS in terms of quality, readiness and fiscal efficiency. This challenge highlights three questions that should be asked. Is the treatment provided of sufficient quality? Is the treatment provided supporting Service Member readiness? Are the dollars being spent providing a satisfactory return on investment? The evidence overwhelmingly supports use of evidence based treatments with requisite fidelity as key to ensuring quality care. Quality is a prime goal of the MHS. Presently, there is relatively limited information on the quality of care received from a quantitative standpoint. Understanding the relative quality of care, or what could be termed a state of the provider force, is essential to taking steps to maintain or improve quality of care delivered. This is critical from the standpoint of fiscal efficiency. The MHS has expended significant funds to provide care to Service Members. Without information on the fidelity or quality of care, it is difficult to say of there has been a significant return on investment. Finally, the MHS understands the importance of troop readiness. Psychological health problems such as PTSD are a threat to Service Member readiness. To that end, the MHS has invested in treatment providers to support returning psychologically injured Service Members to deployment and duty readiness.
At present, there does not appear to be any existing fidelity models within the MHS. As such, the proposed effort is quite unique. Specifically, the information that this type of effort yields would support informed decision making for MHS leadership (quality and fiscal efficiency). The proposed model is cost efficient. A fidelity pilot design could be completed with minimal staff, equipment and travel (if one local location is appropriate). The greatest effort would be directed at development of fidelity check sheets and training of coders; however the cost of these efforts would be minimal compared to the benefit of the information received. Having conducted previous fidelity models, the methodology and design of the study is already conceptually available. The prime challenges will be securing IRB approval and consenting of participants. Despite this, IRB approval can be attained. Further, many clinical therapy sessions are already audio or videotaped as part of normal care delivery. Thus the proposed model would not include an unusual element into therapy sessions. Finally, data would be de-identified and destroyed following coding procedures. This type of model is highly scalable. A pilot model would require limited financial support and minimal staff. Expansion of this type of effort would not require changes in procedures. Rather, it would require some expansion of travel and additional staff to perform coding activity. Through power analysis and targeted sampling, cost minimization could be maintained. This would preserve the projects benefit of significant information for a minimal investment. Moreover, this effort meets the Tri-Service need. A diagnosis of PTSD is uniform across the Services. Similarly, treatment should be uniform. If models such as CPT or PET are delivered as intended, then effectiveness should be stable irrespective if the patient is in the Army, Navy Air Force of Marines. For a minimal investment, MHS leadership can support a meaningful study which is flexible, cost efficient, scalable novel and provides essential information which has been generally unavailable.