Advertisement

Factors Influencing the Implementation of Guideline-Recommended Practices for Postconcussive Sleep Disturbance and Headache in the Veterans Health Administration: A Mixed Methods Study

  • Adam R. Kinney
    Correspondence
    Corresponding author Adam R. Kinney, PhD, OTR/L, Research Health Science Specialist, Rocky Mountain Mental Illness Research, Education and, Clinical Center (MIRECC), Department of Veterans Affairs, 1700 N Wheeling St., Aurora, CO 80045.
    Affiliations
    VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO

    University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
    Search for articles by this author
  • Nazanin Bahraini
    Affiliations
    VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO

    University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation and Psychiatry, Aurora, CO
    Search for articles by this author
  • Jeri E. Forster
    Affiliations
    VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO

    University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
    Search for articles by this author
  • Lisa A. Brenner
    Affiliations
    VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO

    University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Aurora, CO, United States
    Search for articles by this author
Published:February 26, 2022DOI:https://doi.org/10.1016/j.apmr.2022.01.164

      Abstract

      Objective

      Understand barriers and facilitators of implementing recommended practices for postconcussive sleep disturbance and headache, as outlined in the Veterans Administration/Department of Defense 2016 Clinical Practice Guideline (CPG) for mild traumatic brain injury (mTBI).

      Design

      Convergent parallel mixed methods.

      Setting

      Ten national Veterans Health Administration (VHA) facilities.

      Participants

      Twenty VHA stakeholders (14 clinicians; 4 researchers; 2 policymakers), 55% of whom were affiliated with a VHA polytrauma rehabilitation center (N=20).

      Interventions

      None.

      Main Outcome Measures

      Stakeholders rated the quality of recommendations for sleep disturbance and headache using the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence instrument. A descriptive analysis of item scores was performed to understand the following features of the recommendations: (1) clinical credibility (eg, evidence quality), (2) alignment with stakeholder values, and (3) implementability. We conducted semistructured interviews with stakeholders and used descriptive and interpretive analyses to reveal emergent themes. After analyzing the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence and qualitative interview data, we synthesized the results into coherent conclusions (ie, meta-inferences) by comparing and contrasting respective findings.

      Results

      Stakeholders highlighted that the mTBI CPG includes features that reflect clinical priorities (eg, alignment with veteran preferences), making it an appropriate standard of care and facilitating its implementation. However, stakeholders also identified that the design of the mTBI CPG, along with provider-level (eg, knowledge) and facility-level (eg, resources) factors, may create barriers for implementation. In addition to these potential barriers, stakeholders noted a lack of comprehensive and systematic efforts designed to promote the uptake of these recommendations. Findings also revealed stakeholder recommendations for addressing potential barriers (eg, decision support).

      Conclusions

      With the recent release of the 2021 mTBI CPG, decision makers are encouraged to incorporate information gathered from previous implementation efforts to promote adherence to updated recommendations. Study findings, including recommended changes suggested by stakeholders, offer information that can be leveraged to design such efforts and promote care quality and associated outcomes for veterans with mTBI.

      Keywords

      List of abbreviations:

      AGREE-REX (Appraisal of Guidelines Research and Evaluation-Recommendations Excellence), CFIR (Consolidated Framework for Implementation Research), CPG (Clinical Practice Guideline), mTBI (mild traumatic brain injury), VHA (Veterans Health Administration)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bahraini NH
        • Hostetter TA
        • Forster JE
        • Schneider AL
        • Brenner LA.
        A Rasch analysis of the Neurobehavioral Symptom Inventory in a national cohort of Operation Enduring and Iraqi Freedom veterans with mild traumatic brain injury.
        Psychol Assess. 2018; 30: 1013-1027
        • Cassidy JD
        • Cancelliere C
        • Carroll LJ
        • et al.
        Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.
        Arch Phys Med Rehabil. 2014; 95: S132-S151
        • Stein MB
        • Ursano RJ
        • Campbell-Sills L
        • et al.
        Prognostic indicators of persistent post-concussive symptoms after deployment-related mild traumatic brain injury: a prospective longitudinal study in US Army soldiers.
        J Neurotrauma. 2016; 33: 2125-2132
        • Schwab K
        • Terrio HP
        • Brenner LA
        • et al.
        Epidemiology and prognosis of mild traumatic brain injury in returning soldiers: a cohort study.
        Neurology. 2017; 88: 1571-1579
        • Walker WC
        • Franke LM
        • Sima AP
        • Cifu DX.
        Symptom trajectories after military blast exposure and the influence of mild traumatic brain injury.
        J Head Trauma Rehabil. 2017; 32: E16-E26
        • Mac Donald CL
        • Johnson AM
        • Wierzechowski L
        • et al.
        Outcome trends after US military concussive traumatic brain injury.
        J Neurotrauma. 2017; 34: 2206-2219
        • Ferdosi H
        • Schwab KA
        • Metti A
        • et al.
        Trajectory of postconcussive symptoms 12 months after deployment in soldiers with and without mild traumatic brain injury: Warrior Strong Study.
        Am J Epidemiol. 2019; 188: 77-86
        • Scholten JD
        • Sayer NA
        • Vanderploeg RD
        • Bidelspach DE
        • Cifu DX.
        Analysis of US Veterans Health Administration comprehensive evaluations for traumatic brain injury in Operation Enduring Freedom and Operation Iraqi Freedom veterans.
        Brain Inj. 2012; 26: 1177-1184
        • Vanderploeg RD
        • Cooper DB
        • Belanger HG
        • et al.
        Screening for postdeployment conditions: development and cross-validation of an embedded validity scale in the neurobehavioral symptom inventory.
        Journal Head Trauma Rehabil. 2014; 29: 1-10
        • Theeler BJ
        • Erickson JC.
        Mild head trauma and chronic headaches in returning US soldiers.
        Headache. 2009; 49: 529-534
        • Hafner M
        • Stepanek M
        • Taylor J
        • Troxel WM
        • van Stolk C.
        Why sleep matters—the economic costs of insufficient sleep: a cross-country comparative analysis.
        RAND Corporation, Santa Monica, CA2016
        • Stacey A
        • Lucas S
        • Dikmen S
        • et al.
        Natural history of headache five years after traumatic brain injury.
        J Neurotrauma. 2017; 34: 1558-1564
        • Lequerica AH
        • Weber E
        • Dijkers MP
        • et al.
        Factors associated with the remission of insomnia after traumatic brain injury: a traumatic brain injury model systems study.
        Brain Inj. 2020; 34: 187-194
        • Mollayeva T
        • Pratt B
        • Mollayeva S
        • Shapiro CM
        • Cassidy JD
        • Colantonio A.
        The relationship between insomnia and disability in workers with mild traumatic brain injury/concussion: insomnia and disability in chronic mild traumatic brain injury.
        Sleep Med. 2016; 20: 157-166
        • Seal KH
        • Bertenthal D
        • Barnes DE
        • et al.
        Association of traumatic brain injury with chronic pain in Iraq and Afghanistan veterans: effect of comorbid mental health conditions.
        Arch Phys Med Rehabil. 2017; 98: 1636-1645
        • Silverberg ND
        • Iaccarino MA
        • Panenka WJ
        • et al.
        Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines.
        Arch Phys Med Rehabil. 2020; 101: 382-393
        • VA/DoD
        VA/DoD clinical practice guideline for management of concussion-mild traumatic brain injury (mTBI).
        Washington, DC: The Office of Quality and Performance, VA & Quality Management Directorate, US Army Medical Command. 2016;
        • Eakman AM
        • Schmid AA
        • Henry KL
        • et al.
        Restoring effective sleep tranquility (REST): a feasibility and pilot study.
        Br J Occup Ther. 2017; 80: 350-360
        • Fraser F
        • Matsuzawa Y
        • Lee YSC
        • Minen M.
        Behavioral treatments for post-traumatic headache.
        Curr Pain Headache Rep. 2017; 21: 1-9
        • Ludwig R
        • Vaduvathiriyan P
        • Siengsukon C.
        Does cognitive-behavioural therapy improve sleep outcomes in individuals with traumatic brain injury: a scoping review.
        Brain Inj. 2020; 34: 1-10
        • Ulmer CS
        • Bosworth HB
        • Beckham JC
        • et al.
        Veterans Affairs primary care provider perceptions of insomnia treatment.
        J Clin Sleep Med. 2017; 13: 991-999
        • Damschroder LJ
        • Aron DC
        • Keith RE
        • Kirsh SR
        • Alexander JA
        • Lowery JC.
        Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
        Implement Sci. 2009; 4: 50
        • Correa VC
        • Lugo-Agudelo LH
        • Aguirre-Acevedo DC
        • et al.
        Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview.
        Health Res Policy Syst. 2020; 18: 1-11
        • Breimaier HE
        • Heckemann B
        • Halfens RJ
        • Lohrmann C.
        The Consolidated Framework for Implementation Research (CFIR): a useful theoretical framework for guiding and evaluating a guideline implementation process in a hospital-based nursing practice.
        BMC Nurs. 2015; 14: 1-9
      1. VA/DoD. Management and rehabilitation of post-acute mild traumatic brain injury (mTBI). Washington, DC: The Office of Quality and Performance, VA & Quality Management Directorate, US Army Medical Command; 2021.

        • Creswell JW
        • Plano Clark VL
        Designing and conducting mixed methods research.
        3rd ed. SAGE, Thousand Oaks, CA2018
        • Palinkas LA
        • Horwitz SM
        • Green CA
        • Wisdom JP
        • Duan N
        • Hoagwood K.
        Purposeful sampling for qualitative data collection and analysis in mixed method implementation research.
        Adm Policy Ment Health. 2015; 42: 533-544
        • Harris PA
        • Taylor R
        • Thielke R
        • Payne J
        • Gonzalez N
        • Conde JG.
        Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Brouwers MC
        • Spithoff K
        • Kerkvliet K
        • et al.
        Development and validation of a tool to assess the quality of clinical practice guideline recommendations.
        JAMA Network Open. 2020; 3e205535
        • Florez ID
        • Brouwers MC
        • Kerkvliet K
        • et al.
        Assessment of the quality of recommendations from 161 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX) instrument shows there is room for improvement.
        Implement Sci. 2020; 15: 1-8
      2. AGREE-REX Research Team. The Appraisal of Guidelines Research & Evaluation—Recommendation EXcellence (AGREE-REX). Available at: https://www.agreetrust.org/wp-content/uploads/2021/07/AGREE-REX-Tool-PDF-version.pdf. Accessed July 31, 2019.

      3. CFIR Research Team-Center for Clinical Management Research. CFIR interview guide tool. CFIR Research Team-Center for Clinical Management Research. Available at: https://cfirguide.org/guide/app/#/. Accessed March 20, 2020.

        • Elliot R
        • Timulak L.
        Essentials of descriptive-interpretive qualitative research: a generic approach.
        American Psychological Association, Washington DC2021
        • Tong A
        • Sainsbury P
        • Craig J.
        Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32-item checklist for interviews and focus groups.
        Int J Quality Health Care. 2007; 19: 349-357
        • Yardley L
        Demonstrating validity in qualitative psychology.
        Qual Psychol. 2008; 2: 235-251
        • Tashakkori Teddlie C
        Foundations of mixed methods research: integrating quantitative and qualitative approaches in the social and behavioral sciences.
        Sage, Thousand Oaks, CA2009
        • Lee SY
        • Amatya B
        • Judson R
        • et al.
        Clinical practice guidelines for rehabilitation in traumatic brain injury: a critical appraisal.
        Brain Inj. 2019; 33: 1263-1271
        • Berrigan L
        • Marshall S
        • McCullagh S
        • Velikonja D
        • Bayley M.
        Quality of clinical practice guidelines for persons who have sustained mild traumatic brain injury.
        Brain Inj. 2011; 25: 742-751
      4. AGREE Next Steps Consortium. The AGREE II Instrument. Available at: http://www.agreetrust.org. Accessed February 1, 2019.

        • Scholten J
        • Vasterling JJ
        • Grimes JB.
        Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference.
        Brain Inj. 2017; 31: 1246-1251
      5. VA/DoD. VA/DoD clinical practice guideline for the management of chronic insomnia disorder and obstructive sleep apnea. Washington, DC: The Office of Quality and Performance, VA & Quality Management Directorate, US Army Medical Command; 2019.

      6. VA/DoD. VA/DoD clinical practice guideline for the primary care management of headache. Washington, DC: The Office of Quality and Performance, VA & Quality Management Directorate, US Army Medical Command; 2020.

        • Lau MK
        • Bounthavong M
        • Kay CL
        • Harvey MA
        • Christopher ML.
        Clinical dashboard development and use for academic detailing in the US Department of Veterans Affairs.
        J Am Pharm Assoc. 2019; 59: S96-103
        • Dowding D
        • Randell R
        • Gardner P
        • et al.
        Dashboards for improving patient care: review of the literature.
        Int J Med Inform. 2015; 84: 87-100
        • Oliva EM
        • Bowe T
        • Tavakoli S
        • et al.
        Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
        Psychol Serv. 2017; 14: 34-49
      7. Centers for Medicare and Medicaid Services (CMS). CMS Quality Measure Development Plan: supporting the transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) Centers for Medicare and Medicaid Services. Available at:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf. Accessed February 1, 2019.

        • Buscaglia AC
        • Paik MC
        • Lewis E
        • Trafton JA.
        Baseline variation in use of VA/DOD clinical practice guideline recommended opioid prescribing practices across VA health care systems.
        Clin J Pain. 2015; 31: 803-812
        • Bahraini NH
        • Matarazzo BB
        • Barry CN
        • et al.
        Protocol: examining the effectiveness of an adaptive implementation intervention to improve uptake of the VA suicide risk identification strategy: a sequential multiple assignment randomized trial.
        Implement Sci. 2020; 15: 1-12
        • Proctor E
        • Silmere H
        • Raghavan R
        • et al.
        Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.
        Adm Policy Ment Health. 2011; 38: 65-76