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

Research Objectives 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). Design Convergent parallel mixed methods. Setting National Veterans Health Administration (VHA) facilities. Participants 19 VHA stakeholders (13 clinicians; 4 researchers; 2 policymakers) with expertise in managing mTBI. Interventions None. Main Outcome Measures 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. Results 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. Conclusions 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. Author(s) Disclosures None.