Using Mixed Methods to Understand the Implementation of Guideline Concordant Care for Veterans with mTBI

Mild traumatic brain injury (mTBI) is prevalent among Veterans of recent U.S. conflicts, and produces post-concussive symptoms, among the most disabling of which are sleep disturbance and headache. In 2016, the Departments of Veterans Affairs (VA) and Defense (DoD) released a clinical practice guideline (CPG) which outlined evidence-based treatments for post-concussive sleep disturbance and headache. However, evidence-based practices don’t always get delivered in real-world clinical settings. Our team at the VA Rocky Mountain MIRECC was interested in the factors that influence whether guideline-recommended treatments are delivered by VA clinicians in “real-world” clinical settings. The goal was to use such information to develop tailored strategies that target potential barriers to implementation, ensuring that Veterans with mTBI receive the highest quality care. 

“Real-world” rehabilitative care delivery for Veterans with mTBI is influenced by dynamic and complex forces at the levels of the patient, provider, intervention, clinical setting, and broader sociopolitical context. To fully capture this complexity, we needed a holistic research design. By leveraging the complementary advantages of quantitative and qualitative research approaches, mixed methods study designs are ideally suited to achieve a breadth and depth of understanding. This case provides an illustrative example of how we used a convergent parallel mixed methods design, in which quantitative and qualitative data were gathered and analyzed simultaneously, to understand barriers and facilitators to implementing guideline-recommended care for Veterans with post-concussive sleep disturbance and headache. The quantitative portion included a survey administered to 20 VA stakeholders, eliciting quality ratings for CPG recommendations. The qualitative portion was informed by the Consolidated Framework for Implementation Research (CFIR) and included semi-structured interviews with 17 of these stakeholders. In this case, we discuss how we used the CFIR and best practices for mixed methods research to tackle the main challenge of this type of inquiry: synthesizing disparate results into coherent conclusions (i.e., meta-inferences).

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

About this
Applied LeaRRning Case

Adam Kinney, PhD, OTR/L, is an Assistant Professor in the Department of Physical Medicine and Rehabilitation at the University of Colorado Anschutz School of Medicine. This Applied LeaRRning Case is based on a study led by Dr. Kinney which investigated barriers and facilitators to implementing guideline-recommended care for post-concussive sleep problems and headaches in the Veterans Health Administration. In his presentation, Dr. Kinney uses this study to illustrate the unique benefits conferred by mixed methods designs with respect to understanding and improving rehabilitative care quality.

“Mixed methods designs leverage the advantages of quantitative and qualitative studies to achieve a more complete understanding of modifiable factors shaping the delivery of real-world rehabilitative care.”

Adam Kinney, PhD, OTR/L