1. Enhancing Equitable and Effective PTSD Disability Assessment (E3-PTSD) Ted Speroff, PhD, PI; TVHCS Patricia Sinnott, PT, PhD, MPH, co-PI;HERC

2. Study Objective To compare the process and outcomes: –of initial C&P Exams for PTSD conducted with a structured exam –to the process and outcomes of initial C&P Exams conducted as usual.

3. Study Objectives The ultimate aim is to improve the C&P Examination process and To provide Veterans with an exam process that is fair, accurate, equitable and effective across VHA.

4. Research Design A randomized controlled trial to evaluate the effectiveness of the structured exam including: –variation in assessing the DSM-IV components of PTSD, –diagnostic accuracy, –VBA rater utility, –Veteran and Examiner perception of the Exam process, and –resource utilization

5. Study hypotheses Examinations will be more complete and accurate using a structured exam Reports from the structured exam will have greater utility to VBA raters Veteran perception toward the examination will be the same or more positive with the structured exam The structured exam will take longer and thus will have a greater impact on Medical Centers’ budgets than the exams conducted as usual

6. Methods The trial will compare the PTSD Examination process for two study arms: Group 1: A structured Exam process Group 2: Exams conducted as usual by clinical interview.

7. Methods PTSD Examiners will be recruited and randomized to two study groups. Per VA directive, all C&P Examiners will complete the Employee Education Services accredited program, “CPEP Initial Post-traumatic Stress Disorder Examination.”

8. Methods Group 1 Examiners will also undergo a 1.5 day training session on conducting a standardized structured exam.

9. Methods Each Examiner will conduct approximately 10-12 initial PTSD examinations during the study All exams will be audio recorded Audio recordings will be reviewed by experts at National Center for PTSD Examination reports will be additionally reviewed by expert VBA raters After the study, Examiners will be interviewed to address perceived value, barriers, and facilitators to the structured exam strategy.

10. Dissemination will include convening of the Steering Committee, stakeholders, and leaders to review study findings and consider implementation strategies.

11. Key Aim for Economic Study To estimate Medical Center costs to implement both strategies through a budget impact analysis.

12. Hypotheses for Economic Study The costs to deploy training for the structured screening examination will be greater than for standard exams The time needed to complete a structured examination and report will be greater than the time needed for standard exams The costs to provide a structured examination for PTSD will be greater than the costs to provide a standard clinical exam.

13. Budget impact analysis Estimates the financial consequences of adoption and diffusion of a new technology or health care intervention.

14. Budget impact analysis Addresses issue of affordability Provides transparency for decision makers Provides opportunity for decision makers to assess both budget impact, and also how administration might affect costs of implementation (e.g. find efficiencies)

15. Assumption Structured examination will take more time Impact number of –Examinations/week/month –Impact performance mandates –Increase demand for staff/space/support

16. Costs Costs of training: –Training time –Lost clinic time –On-site training/retraining time Examination time –Examiner clinic time –Report writing time –Changes in schedules –Other administrative impacts (?)

17. Data collection At completion of each examination in the study, all Examiners will complete an activity log to define time spent in exam and report writing Cost data from VA centralized databases will be used to estimate the average cost of time spent by Examiners in each arm of the study. Training time and time away from clinic to be standardized for structured interview Examiners

18. Current status Overall –Pilot completed –All forms tested and revised –Study sites recruited; all have IRB and R&D reviews completed –Some RA training completed –Examiner training scheduled (tent) for Jan. –Expect to start veteran recruitment in Jan.

19. HERC data collection instrument Preliminary assumption –C&P Exam scheduled by C&P office –Examiner does examination –Examiner writes/completes report –Report submitted to C&P Office for rating

20. Pilot data form

22. Intermediate assumptions Examiner may be provided some assistance (Professional/staff?) Time may vary from 90 min – 4 hours Scheduled time includes report writing (sometimes) Veteran file/claims statement/discharge information may or may not be available for the exam

23. Final data collection form Scheduling – not clear –Time scheduled or allotted 90 min to 4 hours –Time scheduled does/does not include report writing –Who sets the schedules?

24. Final data collection form Some examiners have veterans routinely complete standardized testing –w/assistant –in separate office at computer Report writing –Some Examiners write/type own reports –Some dictate and review afterwards –Some use CAPRI template (CPRS)

25. Final data form

28. Estimating the cost of Examiner time A priori, the impact of the structured exam on the costs to evaluate veterans for PTSD is unknown.

29. Cost Data Cost of staff time –data from the Financial Management System (FMS), VA’s budget ledger. Cost of VA staff and any non-VA trainers –the nationwide average compensation (salary + benefits) for VA clinical staff having the same job classification (e.g., full-time MD, clinical psychologist). Overhead or department indirect costs will be attributed to staff time.

31. Sensitivity Analyses Testing the sensitivity of our results to a number of assumptions, including –changes in costs/time for the training deployment –changes in the costs of implementation. various possible schedule effects associated with changes in appointment time and report writing

32. Conclusions A key element of any QUERI initiative is the assessment of the economic impact of adopting new methodologies or translating research into practice. A budget impact analysis is frequently needed to determine how much it would cost to implement a new technology or treatment and critical to the design of any implementation strategy.