Factors Influencing the Implementation of Guideline-recommended Practices for Post-concussive Sleep Disturbance and Headache in the Veterans Health Administration

Abstract

<h3>Research Objectives</h3> To increase understanding regarding barriers and facilitators of clinicians' implementation of recommendations for post-concussive sleep disturbance and headache within the VA/DoD mild traumatic brain injury (mTBI) clinical practice guideline (CPG). <h3>Design</h3> Convergent parallel mixed methods. <h3>Setting</h3> National Veterans Health Administration (VHA) facilities. <h3>Participants</h3> 19 VHA stakeholders (13 clinicians; 4 researchers; 2 policymakers) with expertise in managing mTBI. <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> Stakeholders rated recommendations for sleep disturbance and headache on a scale of 1 (low quality) to 7 (high quality) using the psychometrically sound AGREE-REX instrument. A descriptive analysis was performed to understand the recommendations' 1) clinical credibility (e.g., evidence quality); 2) alignment with stakeholder values; and, 3) implementability. We conducted semi-structured interviews with stakeholders and used thematic analysis to reveal factors influencing the implementation of recommendations into care. <h3>Results</h3> Stakeholders rated the recommendations for managing sleep disturbances as clinically credible (mean [M]=5.26, standard deviation [SD]=1.20), consistent with stakeholder values (M=5.00, SD=1.25), and implementable (M=5.05, SD=1.41). Headache recommendations were also rated as clinically credible (M=5.18, SD=0.96), values-consistent (M=5.09, SD=1.14), and implementable (M=5.11, SD=1.41). Preliminary analysis of interviews revealed facilitators of implementing recommendations: 1) evidence underlying recommendations; 2) reflective of Veteran needs/preferences; 3) facility culture; and, 4) access to specialty providers. However, multiple barriers to implementation emerged: 1) inaccessibility at the point-of-care; 2) lack of incentive structure encouraging implementation (e.g., performance standards); 3) varying facility resources; and, 4) lack of formal training. <h3>Conclusions</h3> VHA stakeholders considered the recommendations to be suitable for implementation, but multiple barriers were identified. Findings will inform a discussion of strategies capable of addressing the identified barriers to implementation, thereby maximizing Veterans' receipt of quality rehabilitative care. <h3>Author(s) Disclosures</h3> None.