Test-retest reliability of the VA National Center for Patient Safety culture questionnaire.

RATIONALE, AIMS AND OBJECTIVES: Patient safety culture may have a significant influence on safety processes and outcomes. Therefore, it is important to have valid tools to measure patient safety culture in order to identify potential levers for cultural change that could improve patient safety. The 65-item Department of Veterans Affairs Patient Safety Culture Survey (VA PSCS) consists of 14 dimensions and is administered biannually to VA employees. Test-retest reliability of the VA PSCS has not been established. METHODS: We conducted repeated administrations of the VA PSCS among 28 VA employees. We measured intraclass correlation coefficients for each item and dimension. RESULTS: Test-retest intraclass correlation coefficient values were 0.7 or greater for 13 out of 14 dimensions of the VA PSCS. Employees had difficulty reliably reporting how others feel about patient safety. CONCLUSIONS: In general, the VA PSCS survey showed adequate test-retest reliability. Items asking what others think or feel showed lower reliability. Further work is needed to better understand the relationship between safety culture, safety processes and safety outcomes.

Clinicians' Perception of Patient Readiness for Treatment: An Emerging Theme in Implementation Science?

Despite a training program to help veterans administration (VA) clinicians implement evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), uptake has been limited. To understand clinicians' implementation challenges, we performed thematic analysis of semi-structured telephone interviews guided by the Promoting Action on Research Implementation in Health Services framework. Our sample included 22 psychotherapists in VA PTSD clinics in one region. We identified a theme not captured by our implementation framework: clinicians' perceptions about their patients' readiness for treatment. Clinician perception of patient readiness may be important to the uptake of EBPs and should be considered in mental health implementation work.

Implementation of evidence-based psychotherapies for posttraumatic stress disorder in VA specialty clinics.

OBJECTIVE: The U.S. Department of Veterans Affairs (VA) has engaged in substantial efforts to promote the use of evidence-based psychotherapies for posttraumatic stress disorder (PTSD). The authors evaluated the effectiveness of these efforts. METHODS: This study used a cross-sectional, mixed-methods evaluation of treatment provided by the VA at specialty PTSD clinics in New England during the first six months of fiscal year 2010. Natural language processing algorithms were applied to clinical notes to determine utilization of evidence-based psychotherapy (prolonged exposure therapy and cognitive-processing therapy) among patients who were newly diagnosed as having PTSD. Data regarding efforts to implement evidence-based psychotherapy and other clinic characteristics were obtained through qualitative interviews with clinical and administrative staff (N=30), and the Promoting Action on Research Implementation in Health Services framework was used to identify clinic factors associated with use of evidence-based psychotherapy. RESULTS: Six percent of patients (N=1,924) received any sessions of an evidence-based psychotherapy for PTSD (median=five sessions). Several clinic factors were associated with an increased rate of implementation, including prior experience with use of the treatments, customization of training, and prolonged contact with the implementation and training team. Facilitation with broad training goals and clinics with highly organized systems of care were negatively associated with implementation. CONCLUSIONS: Few patients with PTSD received evidence-based psychotherapy for PTSD during their first six months of treatment at a VA specialty PTSD clinic. The implementation framework poorly predicted factors associated with uptake of evidence-based psychotherapy. These results suggest that additional research is needed to understand implementation of evidence-based therapy in mental health settings.

Inclusion and exclusion criteria in randomized controlled trials of psychotherapy for PTSD.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is a prevalent and often disabling condition. Fortunately, effective psychological treatments for PTSD are available. However, research indicates that these treatments may be underutilized in clinical practice. One reason for this underutilization may be clinicians' unwarranted exclusion of patients from these treatments based on their understanding of exclusion criteria used in clinical trials of psychological treatments for PTSD. There is no comprehensive and up-to-date review of inclusion and exclusion criteria used in randomized clinical trials (RCTs) of psychological treatments for PTSD. Therefore, our objective was to better understand how patients were excluded from such RCTs in order to provide guidance to clinicians regarding clinical populations likely to benefit from these treatments. METHODS: We conducted a comprehensive literature review of RCTs of psychological treatments for PTSD from January 1, 1980 through April 1, 2012. We categorized these clinical trials according to the types of psychotherapy discussed in the major guidelines for treatment of PTSD and reviewed all treatments that were studied in at least two RCTs (N=64 published studies with 75 intervention arms since some studies compared two or more interventions). We abstracted and tabulated information concerning exclusion criteria for each type of psychotherapy for PTSD. RESULTS: We identified multiple RCTs of cognitive behavioral therapy (n=56), eye movement desensitization and reprocessing (n=11), and group psychotherapy (n=8) for PTSD. The most common exclusions were psychosis, substance abuse and dependence, bipolar disorder, and suicidal ideation. Clinical trials varied in how stringently these criteria were applied. It is important to note that no exclusion criterion was used in all studies and there was at least one study of each type of therapy that included patients from each of the commonly excluded groups. A paucity of evidence exists concerning the treatment of patients with PTSD and four comorbidities: alcohol and substance abuse or dependence with current use, current psychosis, current mania, and suicidal ideation with current intent. CONCLUSIONS: Psychological treatments for PTSD have been studied in broad and representative clinical populations. It appears that more liberal use of these treatments regardless of comorbidities is warranted.