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Original Investigation
March 10, 2021

Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
  • 2Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle
  • 3Department of Surgery, UC Davis School of Medicine, Sacramento, California
  • 4Department of Biostatistics, University of Washington School of Public Health, Seattle
  • 5Department of Psychology, Drexel University College of Arts and Sciences, Philadelphia, Pennsylvania
  • 6Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle
  • 7Department of Psychology, University of California, Los Angeles
  • 8Department of Surgery, University of Washington School of Medicine, Seattle
  • 9Department of Emergency Medicine, University of Washington School of Medicine, Seattle
  • 10Department of Children, Youth and Families, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California
JAMA Surg. 2021;156(5):462-470. doi:10.1001/jamasurg.2021.0131
Key Points

Question  Can a brief stepped collaborative care intervention for injured patients at a trauma center delivered by front-line clinicians reduce posttraumatic stress disorder symptoms compared with usual care?

Findings  In a randomized clinical trial with 635 injured patients from 25 US trauma centers, intervention patients demonstrated significant posttraumatic stress disorder symptom reductions compared with those who received usual care at 6 months, but not 12 months, postinjury. Subgroup analyses revealed larger posttraumatic stress disorder treatment effects at trauma centers with good or excellent protocol implementation.

Meaning  In this study, a well-implemented brief intervention for injured patients reduced posttraumatic stress disorder symptoms; policy efforts should incorporate these findings into national trauma center requirements and verification criteria.

Abstract

Importance  To date, few multisite investigations have evaluated early interventions for injured patients with posttraumatic stress disorder (PTSD) symptoms.

Objective  To simultaneously assess the effectiveness and implementation of a brief stepped collaborative care intervention targeting PTSD and comorbidity.

Design, Setting, and Participants  A stepped-wedge cluster randomized clinical trial was conducted at 25 US level I trauma centers. Participants included hospitalized survivors of physical injury who underwent a 2-step evaluation for PTSD symptoms. Patients reporting high levels of distress on the PTSD Checklist (PCL-C) were randomized (N = 635) per the stepped-wedge protocol to enhanced usual care control (n = 370) or intervention (n = 265) conditions. The study was conducted from January 4, 2016, through November 2018. Data analysis was performed from November 4, 2019, to December 8, 2020.

Interventions  The Trauma Survivors Outcomes and Support collaborative care intervention included proactive injury case management that assisted patients transitioning from hospital inpatient to outpatient and community settings. The intervention also integrated evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD symptoms and comorbidity.

Main Outcomes and Measures  The primary study outcome was PTSD symptoms assessed with the PCL-C at baseline in the surgical ward and at 3, 6, and 12 months postinjury. Secondary outcomes included depressive symptoms, alcohol use, and physical function. Subgroup analyses examined the effect of baseline risk factors for enduring PTSD and quality of protocol implementation on study outcomes. Primary statistical analyses were conducted using the intent-to-treat sample.

Results  A total of 327 men (51.5%) were included in analysis; mean (SD) age was 39.0 (14.2) years. The investigation attained follow-up of 75% to 80% of the participants at 3 to 12 months. The intervention lasted a mean (SD) of 122 (132) minutes. Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with control patients at 6 months (difference, −2.57; 95% CI, −5.12 to −0.03; effect size, 0.18; P < .05) but not 12 months (difference, −1.27; 95% CI, −4.26 to 1.73; effect size, 0.08; P = .35). Subgroup analyses revealed larger PTSD treatment effects for patients with 3 or more baseline risk factors for enduring PTSD and for patients, including firearm injury survivors, treated at trauma centers with good or excellent protocol implementation. Intervention effects for secondary outcomes did not attain statistical significance.

Conclusions and Relevance  A brief stepped collaborative care intervention was associated with significant 6-month but not 12-month PTSD symptom reductions. Greater baseline PTSD risk and good or excellent trauma center protocol implementation were associated with larger PTSD treatment effects. Orchestrated efforts targeting policy and funding should systematically incorporate the study findings into national trauma center requirements and verification criteria.

Trial Registration  ClinicalTrials.gov Identifier: NCT02655354

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