evidence based research project final proposal

Running Head: PTSD AND OBESITY IN VETERANS 1

Evidence Based Research Project Final Proposal:

Addressing PTSD and Obesity in Veterans

Randi Bagley

Grand Canyon University:

HCA -699 Evidence Based Research Project

August 9, 2015

PTSD AND OBESITY IN VETERANS 2

Table of Contents

Generating Evidence for Evidence-based Practice

Abstract…………………………………………………………………………………………....5

Section A: Introduction and Problem Description

I. Problem Background……………………………….……………………....…………6

II. Stakeholder/Change Agents……………………………………..…….………..…..6-7

III. Problems and Objectives………………………………………………………………7

IV. PTSD Associated with Diabetes…………………………………………………….7-8

V. Summary of Problem Description…………………………………………………….8

Section B: Literature Support

VI. Introduction to Literature Support……….…………………………….…...…………8

VII. Description of Search Method………………………………………….……...……...9

VIII. Summarization of Research Studies Used as Evidence……………………………9-17

Section C: Solution Description

IX. Introduction and Proposed Solution……………………………………..….........18-19

X. Organizational Culture…..……………………….…………………..…………..19-20

XI. Expected Outcomes and Impact……………………………………………….…….20

XII. Method to Achieve Outcomes………………………………………..…………..21-22

XIII. Summary of Outcome Impact………………………………………………………..22

Section D: Change Model

XIV. Introduction to Stetler Model………………………………………………………..23

XV. Phase I: Preparation………………………………………………………………23-24

XVI. Phase II: Validation………………………………………………………………….24


XVII. Phase III: Comparative Evaluation/Decision Making……………………………24-25

XVIII. Phase IV: Translation/Application………………………………………………...…25

XIX. Phase V: Evaluation………………………………………………………………25-26

Section E: Implementation Plan

XX. Introduction to Plan…………………………………………………………………..26

XXI. Setting and Access………………………………………………………………..26-27

XXII. Time Needed to Complete………………………………………………………..27-28

XXIII. Resources and Changes Needed……………………………………………………..28

XXIV. Methods and Instruments…………………………………………………………….29

XXV. Process for Delivering Solution……………………………………………………...29

XXVI. Data Collection Plan……………………………………………………………...29-30

XXVII. Strategies for Dealing with Barriers……………………………………………..30

XXVIII. Feasibility and Implementation Plan…………………………………………30-31

XXIX. Plan to Maintain, Extend or Discontinue……………………………………….……31

Section F: Evaluation

XXX. Rationale for Methods Used…………………………………………………..….31-32

XXXI. Outcome Measures…………………………………………………………………...33

XXXII. Outcomes Based on Evidence……………………………………………………33

XXXIII. Strategies for Negative Outcomes……………………………………………….34

XXXIV. Implications for Practice and Future Research…………………………………..34

XXXV. Summary of Evaluation………………………………………………………….35

Conclusion………………………………………………..……………………………………...35

References……………………………………………………………………………………36-39


Appendices…………………………………………………………..…………….…………40-51

a) Critical Checklist……………………………………………………………………..40-41

b) Evaluation Table……………………………………………………………………...42-44

c) Conceptual Change Model……………………...........................................................45-46

d) Timeline………………………………………………………………………………….47

e) Resources………………………………………………………………………………...48

f) Methods and Instruments...………………………………………………………………49

g) Data Collection Tool…………………………………………………………………….50

h) Project Budget.…………………………………………………………………………...51


Abstract

The title of this research project is “Addressing Post Traumatic Stress Disorder

(PTSD) and Obesity in Veterans”. The project manager is Randi Bagley, PTA with the Veterans

Healthcare Administration (VHA). The initial investigation for the subject of this research was to

determine why, “Veterans who use the VA for health care have the highest rates of obesity

compared with veterans who do not use the VA and nonveterans” (Nelson, 2006, p.915). The

disease burden of obesity has become an enormous cost to health care here in the United States

(Nelson, 2006). Research for this burden attempts to find out why the burden is greater in the VA

health care system.

Research indicates that, “Veterans have historically been at high risk for mental health

problems, including PTSD” (Salisbury & Burker, 2011, p.3). The statistical significance of the

prevalence of obesity along with the prevalence of PTSD in veterans appeared over and over in

the studies. It was the correlation of these two illnesses that prompted the ensuing investigation

and research.

The evidence from this research will show that PTSD is strongly associated with obesity.

It will further divulge that, while there are several clinical guidelines that target overweight and

obesity, some of these practice guidelines do not currently incorporate PTSD as a risk factor for

developing obesity. This research paper will present a format for modifying existing clinical

practice guidelines to include screening methods for PTSD as a risk factor for obesity.

Additionally, a plan for the introduction and implementation of a new guideline will be included.

By modifying an existing tool, there is an expectation that the change will require a minimal

amount of cost and resources, while incorporating the necessary patient characteristics needed to

affect logical evidence based change in practice.


Introduction

Section A: Problem Description

Background of the Problem

According to numerous studies and research, obesity is becoming an insidious disease here

in the US. Almond, Kahwati, Kinsinger, and Porterfield found that veterans are becoming

alarmingly more obese than their non-military counter-parts (2008). In fact, there are some

disturbing statistics that indicate obesity is on the rise in the veteran population (Almond, et al.,

2008). The question of why veterans in particular are at greater risk for obesity is of great

concern. The common variables and contributing factors to this phenomenon are the main focus

of this investigation. The primary question is: Are veterans who suffer from Post Traumatic

Stress Disorder (PTSD), compared with veterans who do not suffer from PTSD, at higher risk for

developing obesity?

Stakeholders/Change Agents

In addition to discovering why veterans are at such high risk for obesity, the solution to the

epidemic is of equal importance. For some time now clinicians at the Veterans Administration

have developed programs to assist in reducing the rate of obesity in its patient population (Dahn,

et al., 2011). Programs such as the Managing Overweight/ Obesity for Veterans Everywhere

(MOVE) have proven to be a blessing for many veterans struggling with weight management

(Dahn, et al., 2011).

In a comprehensive study, conducted by the CDC (Littman, Boyko, McDonell, and Fihn,

2012), a large cross-section of patients across the Northwest population of the VA Medical


Centers indicated that service members who have served in Iraq or Afghanistan wars (ages 40 –

64) were most likely to seek weight management programs (Littman, et al., 2012). This age

group is more likely to feel that they have control over their health and health related disparities.

Other interesting findings reveal that less than 5% of all veterans identified as being eligible for

the MOVE program elected to participate (Littman, et al, 2012).

Problems and Objectives

It is important to point out that, “Veterans with PTSD frequently pursue service-connected

disability benefits and may therefore attempt to document medical problems by reporting more

symptoms, which may lead to more extensive medical evaluations” (David, Woodward,

Esquenazi & Mellman, 2004, p.85). This is relevant as, further in the context of this research

hypothesis, it will be revealed that service-connected veterans (such as those with PTSD) not

only overuse health care but also are far less likely to actively participate in preventative health

and wellness programs.

The significance of this project will be to point out the implications of overlooking PTSD

as simply a mental health disorder. The hope is to see that there is a strong, statistical correlation

between PTSD and obesity. There is compelling research to suggest that PTSD is associated with

obesity, osteoarthritis, heart disease and diabetes (David, et al., 2004).

PTSD Associated with Diabetes and Obesity

The VA/DoD Clinical Practice Guideline for Screening and Management of Overweight

and Obesity states that “Overweight and obesity are associated with increased prevalence and

worsening of several obesity-associated conditions, including type 2 diabetes” (VA/DoD, 2014,

p.8). Since diabetes is strongly correlated with obesity, it is important to include this group in


this comprehensive research. Many diabetics are at high risk for amputation and, according to

Richardson, et al., over 50% of amputations can be prevented (2014).

Summary of Problem Description

The cost savings associated with preventative care for military veterans is critical. As

Geiling, Rosen and Edwards state in their study, “If we treat a veteran’s PTSD at age 21, with

counseling and lifestyle interventions”, it could prevent self-destructive behaviors (2012,

p.1241). This type of proactive approach may save the healthcare system from having to fund

treatment for largely preventable health disparities (Geiling, et al., 2012).

Section B: Literature Support

Introduction to Literature Support

After working through the reference list that was created for the Evidence Based

Research Project, this section will provide an appraisal for each resource that provides critical

criteria to support the hypothesis. A variety of these sources confirm that veterans are becoming

alarmingly more obese than their non-military counterparts (Almond, et al., 2008). The question

of why veterans in particular are at greater risk for obesity is of great concern.

The primary question, again, for this investigation is to determine: Are veterans who

suffer from Post Traumatic Stress Disorder (PTSD), compared with veterans who do not suffer

from PTSD, at higher risk for developing obesity? Initial findings support this hypothesis. In

addition, there are troublesome statistics that project the increased costs associated with treating

these veterans over time. And finally, the Veterans Administration (VA) health care system’s

solution to this problem may not be enough to win this battle.


Description of the Search Method

Multiple databases were used to search for various studies and research in connection

with this particular subject. This writer met individually with the staff librarian, Loretta Grikis, at

the VA Medical Center in White River Junction, VT to review data and research. In addition to

this, several searches were performed using various databases such as: Scholarly Search via

Google, PubMed, ProQuest and the VA Medical Center’s Knowledge Library which is linked to

virtually every database listed in the text book.

Key search terms included words such as: Veteran, Obesity, PTSD, Military, Evidence-

Based Research, Diabetes and MOVE! Various search terms were initially included at the onset

of the research specifying tours and theaters (theater of war or operation). These were abandoned

based on the exclusionary nature of the data that specific tours and theaters yielded.

Summarization of Research Studies Used as Evidence

The following studies represent the most essential in support of the hypothesis. The

studies are listed alphabetically by the authors’ last name. Components of each study are

described so that readers may evaluate the scientific merit of each, including its strengths and

limitations.

1. The prevalence of overweight and obesity among U.S. military veterans by, Almond, N.,

Kahwati, L., Kinsinger, L. & Porterfield, D. (2008). Military Medicine, 173(6), 544-549

Article Summary


The prevalence of overweight and obesity in veterans are an enormous cost

burden for the Department of Defense (DoD). At the time this article was printed, the estimated

budget was approximately $36 billion and projected to be double that number today.

Design, Strengths and Limitations

The study used a multivariate analysis of data retrieved from the Behavioral Risk Factor

Surveillance System (BRFSS). A large, cross-sectional, randomized survey of veterans and non-

veterans of men and women of all races, ages and income ranges were chosen to best represent a

non-biased group. The results showed that male veterans overall have higher reported percentage

of obesity than their non-veteran counter parts. Female veterans, on the other hand, have a lower

percentage of obesity compared to their non-veteran counter parts. Key findings indicated that

males, specifically between the ages of 35-54, tended to be more obese than non-veteran

counterparts.

The authors admit to several limitations in the study to include much of the data being

self-reported. The overall strength of the study involves the reported trajectory of overweight and

obesity with regard to the veteran population. As Almond, et al states, “Understanding this

trajectory may inform not only the development of military primary preventive efforts but also

nonmilitary behavioral modification programs” (p. 5).

2. Impact of VA Weight Management Program for Veterans by, Dahn, J., Fitzpatrick,

S., Llabre, M., Apterbach, G., Helms, R., Cugnetto, M., Klaus, J., Hermes, F., and Lawler, T.

(2011). North American Association for the Study of Obesity (NAASO).

Article Summary


Managing Overweight/ Obesity for Veterans Everywhere (MOVE) is a weight

management program specifically designed by the VA and targeted for overweight and obese

veterans. The study confirms successful weight loss of those veterans who participated in the

MOVE! Program. The study further suggests that those veterans who actively participated in the

SGS program following the initial SMS education group lost more weight.


This was a quasi-experimental study using a pre and post-test for participants. The data

gathered in this study analyzed the implementation and efficacy of the MOVE program in

Miami. The significant drawbacks to this study are that:

It only reflects 3, 6 and 12-month look backs at participants.

The study was conducted for 27 months overall

The study looked only at one VA Medical Center and is not representative of all

VA centers.

3. Comparison of Comorbid Physical Illnesses Among Veterans With PTSD and Veterans

With Alcohol Dependence by, David, D., Woodward, C., Esquenazi, J. and Mellman, T. (2004).

Psychiatric Services. 55(1). Pp. 82-85.

Article Summary

An in-depth study correlating chronically ill patients with PTSD and those with

alcoholism, this particular article focuses on the impact each of these mental health related

disorders has on veterans. It further dissects each specific disease and associated risks of heart

disease, osteoarthritis, diabetes and liver disease. The information in this study specific to the

research and hypothesis is related to diabetes.



The design of the study was a systematic chart review of male veterans who were

admitted to a rehabilitation unit in the Miami Veterans Affairs Medical Center for chronic PTSD

(N=55) or for alcohol dependence (N=38). They found a prevalence of diabetes among patients

with PTSD (23%) that was significantly higher than other adult males aged 44 to 65 years in the

general population (6%).

The interesting findings associate PTSD with obesity, osteoarthritis, heart disease and

diabetes well over those veterans with alcoholism alone. One limitation the study identified was

that “Veterans with PTSD frequently pursue service-connected disability benefits and may

therefore attempt to document medical problems by reporting more symptoms, which may lead

to more extensive medical evaluations” (p.85).

4. Medical Costs of War in 2035: Long-Term Care Challenges for Veterans of Iraq and

Afghanistan by, Gieling, J., Rosen, J. and Edwards, R. (2012). Military Medicine. 177(11).

pp:1235-1244.

Article Summary

As evident by the title, the study is a projection of costs associated with veterans of the

most recent wars. Not only is there a comprehensive breakdown of costs to care for these

veterans, there is additional speculation about intangible costs such as family support. The

evidence from this study that is most pertinent to the hypothesis lies in the research related to

recognition and early treatment of PTSD and related disorders.



The goal of the study was to “qualitatively list the medical costs of the war on terror and

proactively target those costs that can [be] reduced using medical interventions” (p.1236). Most

of the evidence is predictive and includes economic data projections. The specific data regarding

PTSD patients is critical to the hypothesis for this paper.

5. CDC Evaluation of MOVE! Program for Veterans by, Littman, A., Boyko, E., McDonell,

M. and Fihn, S. (2012). CDC-Preventing Chronic Disease. 0267(9). P.1-12

Article Summary

This particular study suggests that MOVE! is not an effective tool for obesity treatment

and prevention. The study also suggests that service connected veterans are less likely to seek

assistance for weight management than non-service connected veterans. This information is

important as it relates to a pro-active approach to weight management currently being utilized by

the VA health care system in an effort to treat obesity.


This comprehensive study, conducted by the CDC, included a large cross-section of

patients across the Northwest population of the VA Medical Centers. Results indicate that

service members who have served in Iraq or Afghanistan wars (ages 40 – 64) were most likely to

seek weight management programs. This is important because previous studies suggest this age

group has the highest rate of obesity in male veterans.

Data reveals that less than 5% of all veterans identified as being eligible for MOVE

programs elected to participate in weight management programs. In addition, there was no

clinically important weight loss appreciated in those veterans who did experience weight loss

with this program. The CDC further contests the alignment of the purpose of the program with

its implementation and suggests further evaluation of the program’s effectiveness.


6. The Burden of Obesity in Veterans by, Nelson, K. M. (2006). Journal of General Internal

Medicine, 21(9), 915–919.

Article Summary

This study focuses specifically on veterans using the VA compared to those veterans who

do not and non-veterans. The findings revealed astonishing statistics indicating that veterans,

specifically those who use the VA for health care exclusively, have reportedly higher rates of

obesity than their veteran counterparts not using the VA. This is also in comparison to non-

veterans who access public health.

Some of the interesting findings in this study found that, “Veterans who utilized the VA

were less likely to meet national guidelines for physical activity or eat the recommended daily

number of fruits and vegetables than non-veterans” (p.917). The statistics show that an

overwhelming number of veterans who use the VA for their care are older, more prone to obesity

and have a lower median income than their veteran counterparts not using the VA as well as non-

veterans.


This was a bivariate and multivariate analysis research study performed using surveys.

The BRFSS data was accessed for the sampling. This cohort study did not include adults living

in households without telephones. Homeless individuals and persons in prisons or nursing homes

were also not included.


7. Association of Post-Traumatic Stress Disorder and Obesity in a Nationally

Representative Sample by, Pagoto, S., Schneider, K., Bodenlos, J., Appelhans, B., Whited, M.,

Yunsheng, M. and Lemon, S. (2012). Obesity. 20. Pp. 200-205. doi:10.1038/oby.2011.318

Article Summary

This particular study is by far the most important of the study to support the hypothesis.

The study investigated the connection between three variables: Obesity, PTSD and binge eating

disorder (BED) in an effort to determine whether BED has a positive association with PTSD and

obesity. The results found a much higher statistical significant of correlation between PTSD and

obesity than with BED.


This was a multivariate logistic regression model study that included three cross-sectional

surveys. The total sample size was over 20,000. This study is significant to the hypothesis in that

it has such a large sample size and it targets the specific data critical to this paper. Furthermore,

the study points out the association between PTSD and obesity while ruling out a third variable.

The limitation of the study is the fact that it is survey based. This means that the data is

self-reported by the participants. There may have been some discrepancy or error in the actual

data that was reported.

8. Post-Service Eating Behavior and BMI in Veterans by, Smith, C., Klosterbuer, A. &

Levine, A. (2009). Appetite, 52280-289

Article Summary

Post-war veterans were interviewed in an effort to examine how eating behaviors during

active service during wartime may contribute to obesity post-service. In addition to this data, the

interviews also revealed significant discrepancies between the various military sections (Navy,


Air Force, Army) and the quality of food offered to those respective service members at their

dining facilities.


The data was compiled through focus groups and interviews. The results suggest that

many post-war veterans suffered from food deprivation during active service. The study also

identified five major themes during this interview and research process:

A positive correlation of military service and its impact on food environments.

A positive correlation between military service and food insecurity that influences

eating behavior and food choices.

A positive correlation between military service and weight status during and after

service.

A positive correlation between military service negative health consequences

A positive correlation between post-service re-adjustment and negative health

consequences.

9. PTSD as a Risk Factor for Obesity by, Vieweg, W., Julius, D., Bates, J., Quinn III, J,

Fernandez, A., Hasnain, M., & Pandurangi, A. K. (2007). Acta Psychiatrica

Scandinavica, 116(6), 483-487.

Article Summary

The purpose of this particular study is to investigate the correlation of Post Traumatic

Stress Disorder (PTSD) as a potential risk factor contributing to obesity. The study suggests that

PTSD had not been previously linked as a risk factor. The Conclusion, of course, presents a

positive correlation with PTSD and obesity.



The data for this study was massive and accessed national and local PTSD databases. The

sample was comprised of 44,959 male veterans without PTSD and 1819 male veterans with

PTSD. Their height and weight were specific to include those who stood between 60 and 80

inches in height and weighed between 100 and 350 pounds. The drawback of this study is the

lack of female presence in this particular study. It cross-references one VA medical center a

Central VA databank.

10. Implementing the MOVE! Weight-management program in the Veterans Health

Administration, 2007-2010: a qualitative study by, Weiner, B., Haynes-Maslow, L., Kahwati,

L., Kinsinger, L. & Campbell, M. (2012). Preventing Chronic Diseases. 110127(9). DOI:

http://dx.doi.org/10.5888/pcd9.110127

Article Summary

This study, conducted by the CDC, researched the overall implementation of the MOVE

program in order to determine its efficacy and success. Over 120 facilities were invited to

participate in the study, however only 14 accepted. The study did not intend to evaluate

participants. It only sought to determine the success of the program implementation.


A multiple holistic study design was used in order to conduct interviews with providers

and clinicians related to the program. The study compiled an impressive collection of data tables

that pointed out barriers to implementation of the program. While the sample size ultimately was

rather small, the overall findings indicated that the very program intended to screen and treat

obesity in the VA system has been poorly rolled out and is ineffective.


Summary of Literature Support

The initial statistical analysis supports the theory that there is a strong correlation between

PTSD and obesity in veterans. There is additional research to suggest that one of the programs

used by the VA healthcare system to target obesity is ineffective. Supportive research suggests

treating PTSD early as a comorbid factor in obesity. Further research and evidence will be

presented to solidify these findings.

Section C: Solution Description

Introduction to Solution

The purpose of this section is to provide a solution to the hypothesis statement: Are

veterans who suffer from Post Traumatic Stress Disorder (PTSD), compared with veterans who

do not suffer from PTSD, at higher risk for developing obesity? While the answer to this

question, according to evidence-based research studies, is a resounding yes, the solution must lie

in targeting those veterans who suffer from this disorder. Preventing PTSD is an unlikely

approach, since this would presume that trauma is preventable in tactical operations during active

duty. According to Perkonigg, Owashi, Stein, Kirschbaum and Wittchen, “The prevention of

obesity might be partially achieved through the recognition and treatment of PTSD symptoms”

(2009, p. 18).

Proposed Solution

In addition to early recognition and treatment of PTSD symptoms, addressing obesity is

of equal importance. For some time now clinicians at the Veterans Administration have

developed programs to assist in reducing the rate of obesity in its patient population (Dahn, et al.,

2011). Programs such as Managing Overweight/ Obesity for Veterans Everywhere (MOVE) have


proven to be a blessing for many veterans struggling with weight management (Dahn, et al.,

2011). Frayne, et al., state that the Veterans Healthcare Administration (VHA) should begin

focusing their efforts on increased mental health services as well as medical services for

returning veterans with PTSD (2011).

Frayne, et al propose that the VHA may need to augment their care for veterans to

include early intervention for musculoskeletal conditions to address pain, behavioral health,

hearing problems and early cardiovascular screenings (2011). Early testing to detect

hyperlipidemia and hypertension would also be beneficial (Frayne, et al., 2011). David, et al.,

(2004) found that many of the PTSD patients in their study were actually taking lipid-lowering

supplements for their high cholesterol, compared to none of the alcoholism patients, and lab tests

showed higher levels of lipids in the PTSD group (2004). For that reason, early detection and

treatment of hyperlipidemia in PTSD patients would seem prudent as it is clearly correlated with

the associated risk for obesity.

Organization Culture

The Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI)

has already implemented some changes to address this epidemic. Their “prevention research and

implementation programs focus not only on diabetes prevention, but more broadly on obesity

prevention and treatment, promotion of physical activity, and cardiovascular risk reduction [for

veterans]” (Richardson, et al., 2014, p.2). Since diabetes is strongly correlated with obesity, it is

important to include this group in this comprehensive research and solution. Many diabetics are

at high risk for amputation and, according to this QUERI, over 50% of amputation can be

prevented. In addition to this data, the document states that obese veterans have more specific


co-morbidities preventing effective weight loss. Some of the important co-morbidities include

PTSD, binge eating disorders and other serious mental health issues. Many of these disorders

cannot be addressed using conventional behavioral weight loss programs. Hence, MOVE is

specifically targeted to meet the needs of these veterans.

If the statement “millions of high-risk individuals can avoid or delay developing type 2

diabetes through weight loss, improved diet and physical activity” is true, than we can conclude

that increased vigilance in treatment for patients with PTSD can significantly reduce the overall

financial burden the VA is currently experiencing (Richardson, et al., 2014, p.8). According to

Gieling, et al., “If rates of price inflation and prevalence were to remain unchanged, the per-

person societal cost [for treatment of PTSD related comorbid conditions] could reach nearly

$50,000 over 2 years by the year 2035” (2012, p. 1239). The projected cost over a 50-year period

might reach an estimated $1,250,000 just to treat depression and PTSD in one veteran (Gieling,

et al., 2012).

Expected Outcomes and Impact

Gieling, et al., suggest that our “best hope of containing costs may be to screen and treat

PTSD early, along with related physical-health consequences” (2012, p.1239). Early treatment

with increased access to mental health providers as well as increasing participation in the MOVE

program may facilitate reduced overall costs and reduced risk for obesity. Results from a study

conducted by the Centers for Disease Control and Prevention (CDC) indicate that service

members who have served in Iraq or Afghanistan wars (ages 40 – 64) were most likely to seek

weight management programs (Littman, et al., 2012). This is important because previous studies

suggest this age group has the highest rate of obesity in male veterans.


Method to Achieve Outcomes

The following is a recommended outline taken from the VA/ Department of Defense (DoD)

Clinical Practice Guideline for Screening and Management of Overweight and Obesity for early

intervention of patients suffering from overweight and obesity. For the purposes of this evidence

based-research proposal, additional interventions have been added by, this writer in order to

more fairly represent the PTSD population of veterans. The VA/DoD guideline did not correlate

PTSD with obesity, however, based on compelling research, it is evident that they are in fact

related:

Screen adult patients to establish a diagnosis of PTSD, overweight or obesity and

document the presence of these conditions in the medical record.

Screen for PTSD, overweight and obesity at least annually.

Assess for the presence of obesity-associated conditions (such as PTSD) among

overweight patients or patients with increased waist circumference.

Perform a targeted assessment on overweight and obese patients. In addition to the basic

medical history and physical examination, assess for factors contributing to obesity such

as PTSD.

Offer obese patients with PTSD comprehensive lifestyle intervention for weight loss to

improve lipid levels, blood pressure and/or glucose control.

Convey the importance of weight loss and weight management as a lifelong commitment.


Offer counseling and referrals to skills physical fitness experts and the MOVE program.

Offer dietary counseling and referrals for appropriate dietary management groups.

Offer Psychiatric intervention and ongoing counseling for the aforementioned and

associated clinical conditions. (VA/DoD, 2014, p.17)

Summary of Outcome Impact

The prevalence of overweight and obesity in veterans are an enormous cost burden for

the Department of Defense (DoD). The estimated budgetary expense was approximately $36

billion as of 2008 and projected to be double that number today (Almond, et al., 2008). Some

key findings from the Almond, et al.’s article suggest that males, specifically between the ages of

35-54, tended to be more obese than non-veteran counterparts (2008). Since previous research

also suggests that veterans with similar sample characteristics were most likely to seek weight

management programs, it is reasonable to conclude that the proposed interventions will be well

received and effective (Littman, et al., 2012).

The potential outcome and advantage to performing this essential early screening and

referral process will help to reduce the associated cost for PTSD associated obesity. Since the

hypothetical associate between PTSD as a comorbid factor strongly correlates with obesity

(Pagoto, et al 2012), and obesity strongly correlates with diabetes and other preventable

conditions (VA/DoD, 2014), timely intervention of these associated conditions will be highly

effective in reducing overall costs for care. Programs such as MOVE, increased mental health

intervention and increased screening for hyperlipidemia or dyslipidemia can provide essential

preventative treatment of PTSD associated obesity.


Section D: Change Model

Introduction to Change Model

The purpose of this section is to apply the Stetler Model as a framework for the proposed

evidence-based intervention. The preliminary framework for the intervention is covered in detail

within the VA/ Department of Defense (DoD) Clinical Practice Guideline for Screening and

Management of Overweight and Obesity for early intervention of patients suffering from

overweight and obesity. For the purposes of this evidence-based intervention plan, additional

data has been added in order to more fairly represent the Post Traumatic Stress Disorder (PTSD)

population of veterans as the VA/DoD guideline did not correlate PTSD with obesity in their

guideline.

The Stetler Model

The Stetler model is divided into five progressive categories that correlate to the phases

of activity required to implement the change (Melnyk & Fineout, 2011). Using each category as

a heading, the change model will evolve by incorporating the strategic initiative presented by the

VA/DoD. The hope is that the guideline can be modified in order to include the early treatment

and intervention of PTSD as it has been proven to be strongly associated with obesity.

Phase I: Preparation


The Stetler Model requires an initial affirmation of the priority and need for change

(Melnyk & Fineout, 2011). Because obesity is a growing epidemic and treatment of its

comorbidities is costly, recognizing the associated conditions of this disease is imperative.

Supporting research has established a consistent pattern of PTSD positively correlating with

obesity.

The context for use and implementation of the research would be easily incorporated with

the existing guideline intended for use by the VA/DoD. The search for relevant evidence has

been completed and the statistical support is overwhelmingly strong with regard to associating

PTSD as a link to obesity. Additional comorbidities have been identified previously in the

VA/DoD literature, but the guideline comes short of associating PTSD with obesity.

Phase II: Validation

The qualifying assessments have been well documented within the previous stages of this

paper. In order to validate this assertion, a variety of research material has been investigated to

include quantitative and qualitative methodologies in an effort to triangulate the data (Melnyk &

Fineout, 2011). The research incorporates studies performed using surveys, face-to-face

interviews as well as statistical analyses and comparative data.

Phase III: Comparative evaluation/decision making

Once the evidence has been summarized and synthesized from the research, the

stakeholders at the VA and DoD will need to make a decision about whether or not to implement

the modifications to their existing practice guideline. Utilization criteria will need to be

determined that will align with the present guideline (Melnyk & Fineout, 2011). The


modifications have been suggested in previous sections of this proposal and would require

inclusion criteria for pre-screening of patients with PTSD.

A conceptual model of this plan is provided in Appendix C (pp.45-46) and will provide a

strategic flow chart for the implementation. The decision-making flow chart allows providers a

clear understanding of how and when to implement assessments for patients with PTSD. It also

provides an understanding of the steps to incorporate these screenings.

Phase IV: Translation/application

The following steps will assist the VA/DoD to convert the findings from the research into an

appropriate screening tool. The change will be implemented via operational dissemination of the

information. The existing guideline will need to be augmented in order to reflect the need for

critical assessment of PTSD patients. A sample of the changes will look like the list provided on

pages 19-20 of this proposal.

Phase V: Evaluation

The last step to the process implementation will require a formal evaluation of the plan

(Melnyk & Fineout, 2011). Since the potential outcome and advantage to performing this

essential early screening and referral process will help to reduce the associated cost for PTSD

associated obesity, evaluating the effectiveness may require long range financial assessment.

There is little, if any, risk in implementing this plan as it can only enhance current practices.

As has been previously stated, there is a hypothetical association between PTSD as a

comorbid factor that strongly correlates with obesity. Obesity strongly correlates with diabetes


and other preventable conditions. Timely intervention of these associated conditions will likely

be highly effective in reducing overall costs for care.

The ultimate goal for the change model is not necessarily to replace a current practice.

Rather, the plan is intended to be an enhancement of current practice. By providing key

information to providers regarding the correlation between PTSD and obesity, appropriate and

timely referrals can occur.

Section E: Implementation Plan

Introduction to Implementation Plan:

This section of the paper will provide a description of the methods to be used to implement

the proposed solution for the problem identified in the hypothesis statement. Since the initial

statement provides a correlation between Post Traumatic Stress Disorder (PTSD) and obesity,

the solution must lie in targeting those veterans who suffer from this disorder. Preventing PTSD

is an unlikely approach, since this would presume that trauma is preventable in tactical

operations during active duty. Through extensive studies and research, “The prevention of

obesity might be partially achieved through the recognition and treatment of PTSD symptoms”

(Perkonigg, et al., 2009, p. 18).

Setting and Access to Potential Subjects

Because this particular evidence based change/intervention is not intended as an invasive

treatment, there is no perceived need for consent or approval forms. The department of Veterans


Affairs is the target setting for the plan implementation. The VA has access to the specific

patient population that is affected by the applicable research.

There is a potential that the strategic implementation plan could carry over to civilian

organizations as well. The VA system currently has a Choice program that offers veterans

already enrolled in the VA health care system to access healthcare from non-VA physicians and

providers (VA, 2015). Because these veterans will have access to outside facilities, the VA

system may benefit from sharing the information with supporting providers. The emphasis on the

successful implementation of the plan with the VA will determine its efficacy and the need to

share with outside organizations.

Time Needed to Complete the Project

The timeline is included in Appendix D (p.47). The specific narrative criteria will require a

12-month timeframe to introduce and implement the plan. The initial steps will include providing

critical information from the research findings to support the change.

The first month will entail educating VA officials, namely, Dr. David Shulkin, Under

Secretary of Health, regarding the evidence accumulated to support the recommended change

(VA, 2015). Once the evidence has been presented, the plan can be acted on accordingly. The

steps in this paper will outline the details of the process.

Within three months, it is projected that providers will have been alerted to the evidence

supporting PTSD correlating with obesity. During that time, additional efforts will be made to

modify the existing VA/ Department of Defense (DoD) Clinical Practice Guideline for Screening


and Management of Overweight and Obesity to include early intervention of patients suffering

from PTSD. The modifications will align well with the current guideline.

Within six months, the modified guidelines will be distributed to all VA facilities. Prior the

distribution, practitioners will be educated regarding the evidence and necessity for change

practice. By using the strategies in the Stetler Model, appropriate information and supportive

literature will be provided to clinicians. As stated by Melnyk & Fineout, “Without targeted

critical thinking at that level, application of research may become a task- oriented, mechanistic

routine that can lead to inappropriate, ineffective, and non– evidence based practice” (2011, p.

246).

In twelve months, the cycle of education, implementation and evaluation should be complete.

There will be a need for administrative support to include and implement this plan in an on-going

fashion for all new providers hired within the system. This will ensure that the cycle continues.

Resources and Changes Needed

The fundamental clinical tool for the implementation of this process will be the VA/

Department of Defense (DoD) Clinical Practice Guideline for Screening and Management of

Overweight and Obesity. The personnel resources will include the Under Secretary of Health for

the VA Healthcare System as well as respective facility administrators. The specific list of

individuals is included in the appendices.

Financing for the implementation is a strong consideration. Funding for the modification and

re-distribution of existing clinical tools will require approximately $7,800 - &17,000 for optional

copying and distributing. The cost for additional education and implementation are outlined on


the next page and in Appendix H (p.51). The expectation is that no further outside resources will

be required other than the replacement of the existing guides.

Methods and Instruments

The methods and instruments will be covered in greater detail in Appendix F (p.49). The

method for introducing the concept and education will require either face-to-face consultation or

tele-health chat. Tele-health is a system that has been utilized by the VA system for years. It

allows clinicians and administrative personnel to consult with patients and one another in real

time using cameras (VA, 2015). There is also a feature that allows administrators to record

important information and send it to VA employees (VA, 2015). In addition to this process, the

VA also uses the Talent Management System (TMS) to provide continuing and required

education to employees (VA, 2015).

Process for Delivering the Intervention / Solution

There will be a requirement to educate each administrator as well as head of each education

department at each VA. These agents will facilitate the implementation of the newly modified

guideline. The most critical element of the plan is the education and inclusion of all primary care

providers.

Data Collection Plan

Data management is a large aspect of the VA system. There are various tools for tracking and

detecting the interventions required of veterans built into the VISTA data system used by the


VA. As the VA/DoD guideline points out, prompts will guide clinicians to perform specific

assessments (2014).

The data analysis and interpretation should be conducted over the course of a 12-36 month

period in order to track any specific changes or improvements. Administrators and education

professionals within the VA system can also track employees’ compliance with tools by

accessing the TMS system. These tools are readily available to all department heads and

administrators for their respective employees (VA, 2015). Details of this method will be

provided in Appendix F (p.49).

Strategies to Deal with the Management of Barriers

The facilitators for the change within each facility will be the administrator and the

respective head of education. While there are always perceived challenges with the

implementation of a change in practice, it is less likely to find this in an organization that is

already committed to the treatment of veterans suffering from PTSD. Because the framework has

been loosely implemented already, this will likely be seen as an augmentation of an existing

program. An outline of this will be provided in the appendices.

Feasibility of the Implementation Plan

With respect to costs and consumable supplies, there is no significant barrier to the

implementation. As previously stated, all of the framework and training necessary currently

exists within the VA health care system. There is access to tele-health, computers and additional

technologies necessary to facilitate the designated plan.


There will be a cost associated with the recruitment and implementation of an administrative

role to facilitate the plan and follow the process from beginning to end. The original convening

board, referred to in Appendix E, will require an estimated timeframe of one hour a week for

approximately four weeks to review changes to the existing guideline. An administrator/IT

position will be required to upload the newly revised tool into the TMS system and to

disseminate PDF files to all personnel. The only additional cost would likely be a replacement

manual (listed as an optional expense in Appendix H on page 51) that could be copied and issued

to each facility once the modifications have been made.

Plan to Maintain, Extend, Revise, and Discontinue

Within the context of the change model, an evaluation process has been included. This

step will involve assessing the efficacy of timely assessment for and intervention of PTSD, as it

is associated with obesity. There will be an opportunity to discontinue the screening practice,

should it be determined that it is ineffective. The overall hope is to provide the necessary

education to providers in an effort to identify patients who’s associated conditions correlate with

obesity. Additionally, the predicted outcome is to reduce incidences of preventable and costly

health related conditions.

Section F: Evaluation

Introduction to Evaluation

The purpose of this section is to explain the rationale for the methods used in collecting the

outcome data for this evidence based research project. It will also describe the ways in which the

outcome measures evaluate the extent to which the project objectives are achieved. Additionally,


this section will demonstrate how the outcomes will be measured and evaluated based on the

evidence and address validity, reliability, and applicability. Lastly, it will provide strategies to

take if outcomes do not provide positive results while also describing implications for practice

and future research.

Rationale for Methods Used in Collecting Outcome Data

The methods used to collect the outcome data are essentially derived from previous studies

and include quantitative and qualitative methodologies. This particular research combines both

types of methodologies in an effort to triangulate the data. It incorporates studies performed

using surveys, face-to-face interviews as well as statistical analyses and comparative data.

The problem was formulated using the PICOT etiology format. The specific population (P) is

intended to represent veterans. The issue of interest (I) includes veterans with post-traumatic

stress disorder (PTSD). The comparison (C) involves those veterans without PTSD. The outcome

of interest is a correlation with risk for obesity (O). And there is no specific timeframe to

demonstrate the outcome (T).

The question looks like: Are (P), who have (I) compared with those without(C) at risk for/of

(O) over (T)? In other words, are veterans (P) who suffer from PTSD (I), compared with veterans

who do not suffer from PTSD (C), at higher risk for developing obesity (O)?

Data was collected through research. In the particular studies used, there were a variety of

multivariate studies that included surveys, interviews and retrospective data analysis. Various

methods were used for data collection including surveys, interviews and patient records as well

as database analyses. In order to best capture large numbers of patients and to track their


progress and etiologies, the data, interviews and surveys were imperative to finding the

association between PTSD and obesity.

Outcome Measures

Richardson, et al. note in their QUERI that, “VHA performance measures are generally

consistent with those used outside VHA to facilitate comparisons between VA and non-VA care”

(2014, p.19). With the vast amount of technology and statistical resources available in the VA

healthcare system, there is no doubt that measuring the efficacy of a program that includes PTSD

as a correlating factor to obesity, will be easy to track. Because the QUERI, implemented by the

VA, focuses on specifically targeted outcomes of lipid management in veterans, “to promote the

effective implementation of risk based rather than target based treatment” (Richardson, et al

2014, p. 21).

These outcome measures will be useful for the implementation of the plan proposed in this

research project because previous studies have suggested a strong correlation between

dyslipidemia and PTSD (David, et al., 2004). Researchers found that many of the PTSD patients

in their study were actually taking lipid-lowering supplements for their high cholesterol,

compared to none in their control group, and lab tests showed higher levels of lipids in the PTSD

group (2004). This link is critical for measuring outcome data for this project.

Outcomes Based on Evidence

The specific outcome for this project will be measured and evaluated based on blood tests to

determine lipid levels. Additionally, height and weight measurements will be required to track

the prevalence of obesity and weight loss in patients who are participating in the solution plan. It


would be vital to include a control group of patients who do not have associated risk factors to

use as a comparison in order to prove the validity and reliability of the data.

Strategies for Negative Outcomes

As stated by Richardson, et al, “to be effective (and efficient) most programs that

improve outcomes for patients with chronic conditions rely on informed and activated patients

who are engaged in self-management activities that need to be supported” (2014, p.23). Because,

as the authors state,

“Veterans with serious mental illness might be less likely to engage in [supportive weight

loss and weight management programs] and are less likely to remain in the program over

time and less likely to experience weight loss even with intense and sustained

intervention exposure”, it is vital to find a program that these particular patients will

respond to (Richardson, et al 2014, p.28).

Within the VA system, there are many opportunities for tracking this data and to encourage these

veterans’ participation in meaningful programs.

Implications for Practice and Future Research

The vital information contained within this evidence-based research project can be an

excellent resource for the implementation of proactive changes in the way the VA health care

system evaluates and treats patients with PTSD. The VA/ Department of Defense (DoD) Clinical

Practice Guideline for Screening and Management of Overweight and Obesity, currently in place

will serve as a suitable vehicle for this plan. By modifying the existing clinical guideline and


including critical screening for patients with PTSD, the enhanced opportunities in treatment

options for these patients would be substantial.

Summary of Evaluation

The specific PICOT question for this study is based on etiology, therefore, planning for

and implementing a change is not as easy to measure as other statistical studies. The statistical

significance of the correlation between PTSD and obesity is overwhelmingly positive. The

question will remain whether or not there will be a clinical significance once the plan has been

implemented.

A Brief Conclusion

The basis for the study itself is to present considerable evidence regarding the associated

risk for obesity with patients suffering from PTSD. By compiling the various studies and

presenting them with an appropriate vehicle for change in practice, the hope is for an increase in

recognition of conditions associated with obesity. Changing clinical guidelines for screening is

the first step toward effecting outcomes.


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Appendix A

Critical Appraisal Checklist Summary*

Eighteen peer-reviewed resources found to support the problem and/or solution

o Eleven research studies (see evaluation table in Appendix B):

Seven Multivariate Data Analysis reviews

Only randomized controlled trials

Detailed description of search strategy

Description of validity of individual studies

Results consistent across studies

Used individual patient data and aggregate data in analysis

Statistically significant results reported; reliability validated

Patients similar to this project’s population

Feasible to implement in this project’s setting

One Case-Control study

All instruments used for measurements reliable and valid

Statistically significant results reported

Patients and setting similar to this project

One Quasi-Experimental study


Intervention or treatment precise




Three descriptive cross-sectional studies




o Two clinical guidelines/consensus statements

Credible developers and researchers

Sensible and impartial strategies and processes

Recommendations are clinically relevant and feasible

Recommendations are not a major variation from current

practice

o Seven additional articles/summaries

Peer-reviewed with credible references

Recommendations suitable for practice

*Adapted from Melnyk & Fineout-Overholt, 2010.


Appendix B

Evaluation Table Authors/Year of

CitationResearch

DesignData

Collection Methods

Sample Characteristics

Key Findings

Almond, Kahwati, Kinsinger and Porterfield,2008

Multivariate analysis

Behavioral Risk Factor Surveillance System (BRFSS)

Veterans and non-veterans of all ages and sexes

Males between the ages of 35-54 tend to be more obese than non-veteran counterparts.

Dahn, Fitzpatrick, Llabre, et al 2011

Quasi-experimental Pre/post test

Historical data capturing

Obese veterans in Miami who utilize Miami VA

MOVE program may be ineffective in treating patients with obesity, Inconclusive

David, Woodward, Esquenazi & Mellman, 2004

Control Group Study

Review of discharge summaries

Male veterans who were admitted to a rehabilitation unit in the Miami Veterans Affairs Medical Center for chronic PTSD (N=55) or for alcohol dependence (N=38).

The prevalence of diabetes among patients with PTSD in our study (23%) was significantly higher than that reported among adult males aged 44 to 65 years in the general population (6 %).

Frayne, S. et al., (2011).

Cross-sectional study using existing databases (FY 2006-2007)

Data came from VHA’s National Patient Care Database

90,558 OEF/OIF veterans using VHA categorized into strata

PTSD is linked with a high prevalence of medical illness compared to those veterans without PTSD or other mental health conditions


Authors/Year of Citation

Research Design

Data Collection Methods


Key Findings

Geiling, Rosen and Edwards, 2012

Multivariate analysis

Historical data capturing combined with projected expenditures

Statistical analysis of trauma and poly-trauma associated costs for treating veterans of various theaters of war.

Prioritize initiatives that would help maintain primary mobility, functionality and physical activity for amputees, and support rehabilitation for PTSD or TBI so that the wounded veteran could work productively and engage in society

Nelson, 2006 Bivariate and multivariate analysis

Surveys Veterans who use and do not use VA for care and rate of obesity with non veterans

Veterans who receive care at the VA have higher rates of overweight and obesity than the general population.

Pagoto, et al. 2012 Multivariate logistic regression models

Three cross-sectional surveys

Measures of PTSD, Obesity and BED (binge eating disorder)

Past year PTSD was associated with increased likelihood of being obese

Perkonigg, et al. (2009).

Cross-sectional studies

10-year Prospective, longitudinal, epidemiologic study

Total sample of 3021 community patients aged 14-24 years old at the onset of the study.

10-year follow-up, a statistical significance was found to associate PTSD with obesity. No clinical significance noted.


Authors/Year of Citation

Research Design

Data Collection Methods


Key Findings

Smith, Klosterbuer and Levine, 2009

Data analysis Focus group discussions

Sixty-one male and three female American military veterans, with an average age of 57 years

Food association and obesity post service

Vieweg, et al. 2007 Data analysis Accessed both a national and local database of PTSD veterans.

44 959 male veterans without PTSD and 1819 male veterans with PTSD who stood between 60 and 80 inches in height and weighed between 100 and 350 pounds

Post-traumatic stress disorder may be a risk factor for overweight and obesity among male military veterans.

Weiner, et al 2012 Qualitative data analysis

Multiple, holistic case study design,

68 clinicians responsible for the MOVE program

Barriers to program implementation


Appendix C

Stetler Model for Change*

*Adapted from the Stetler Model (Melnyk & Fineout-Overholt, 2010, p. 248)


Appendix C Continued

*Stetler Model of EBP Five Phases

Phase I: Preparation Phase II: Validation

Phase III: ComparativeEvaluation/Decision Making

Phase IV:Translation/Application

Phase V:Evaluation

Purpose, Context, & Sources of Evidence:• Potential Issues/Catalysts = a problem, including unexplained variations; less-than-best practice; routine update of knowledge; validation/routine revision of procedures, etc.; or innovative program goal• Affirm/clarify perceived problem/s, with internal evidence re: current practice [baseline]• Consider other influential internal and external factors, e.g., timelines• Affirm and focus on high priority issues• Decide if need to form a team, involve formal stakeholders, &/or assign project lead/facilitator• Define desired, measurable outcome/s• Seek out systematic reviews/guidelines first• Determine need for an explicit type of research evidence, if relevant• Select research sources with conceptual

Credibility of Evidence & Potential for/Detailed Qualifiers of Application:• Critique & synopsize essential components, operational details, and other qualifying factors, per source° See instructions for use of utilization-focused review tables with evaluative criteria, to facilitate this task; fill in the tables for group decision making or potential future synthesis• Critique systematic reviews and guidelines• Re-assess fit of individual sources• Rate the level & quality of each individual evidence source per a “table of evidence”• Differentiate statistical and clinical significance• Eliminate non-credible sources• End the process if there is clearly insufficient, credible external evidence that meets your need

Synthesis & Decisions/Recommendations per Criteria of Applicability:• Synthesize the cumulative findings:°Logically organize & display the similarities and differences across multiple findings, per common aspects or sub-elements of the topic under review° Evaluate degree of substantiation of each aspect/sub-element; reference any qualifying conditions for application• Evaluate degree & nature of other criteria: feasibility (r,r,r = risk, resources, readiness); pragmatic fit, including potential qualifying factors to application; & nature of current practice, including the urgency/risk of current issues/needs• Make a decision whether/what to use:° Can be a personal practitioner-level decision or a recommendation to others° Judge strength of decision; indicate if primarily “research-based” (R-B) or, per hi use of supplemental info, “E-B”; note level of strength of recommendation/s per related table; note any qualifying factors that may influence individualized variations• If decision = “Not use” research findings:° May conduct own research or delay use till additional research done by others° If still decide to act now, e.g., on evidence of consensus or another basis for practice, consider need for similar planned change and evaluation.• If decision = “Use/Consider Use,” can mean a recommendation for or against a specific practice

Operational Definition of Use/Actions for Change:• Types = cognitive/conceptual, symbolic &/or instrumental• Methods = informal or formal; direct or indirect• Levels = individual, group or department/organization• Direct instrumental use: change individual behavior (e.g., via assessment tool or Rx intervention options); or change policy, procedure, protocol, algorithm, program, etc.• Cognitive use: validate current practice; change personal way of thinking; increase awareness; better understand or appreciate condition/s or experience/s• Symbolic use: develop position paper or proposal for change; or persuade others regarding a way of thinking• CAUTION: Assess whether translation/product or use goes beyond actual findings/evidence:° Research evidence may or may not provide various details for a complete policy, procedure, etc.; indicate this fact to users, and note differential levels of evidence therein• Formal dissemination & change strategies should be planned per relevant research and local barriers:° Passive education is usually not effective as an isolated strategy. Use Dx analysis & an implementation framework to develop a plan. Consider multiple strategies: e.g., opinion leaders, interactive education, reminders & audits.° Focus on context& to enhance sustainability of organizational-related change• Consider need for appropriate, reasoned variation• WITH B, where made a decision to use in the setting:° With formal use, may need a dynamic evaluation to effectively implement & continuously improve/refine use of best available evidence across units & time• WITH B’, where made a decision to consider use & thus obtain additional, pragmatic information before a final decision° With formal consideration, do a pilot project° With a pilot project, must assess if need IRB review, per relevant institutional criteria

Alternative Evaluations:• Evaluation per type, method, level: e.g., consider conceptual use at individual level&&• Consider cost-benefit of change + various evaluation efforts• Use RU-as-a-process to enhance credibility of evaluation data• For both dynamic & pilot evaluations include:° Formative, regarding actual implementation & goal progress° Summative, regarding identified end goal and end-point outcomes

*Adapted from the Stetler Model of EBP Five Phases (Melnyk & Fineout-Overholt, 2010, p. 298)


Appendix D

Project Timeline (12 Months)

Tasks

1

2

3

4

5

6

7

8

9

1

0

1

1

1

2

Form Steering Committee: Create proposal Educate VA officials -

Staff Meetings: Engagement Training

Modification of Current Guideline Feedback

Implement Guideline VA-wide: Correlate Data

-

Evaluate/analyze results: Revise guideline as needed Institutionalize practice Disseminate results


Appendix E

Resources

The fundamental clinical tool for the implementation of this process will be the VA/

Department of Defense (DoD) Clinical Practice Guideline for Screening and Management of

Overweight and Obesity. The personnel resources will include Dr. David Shulkin, Under

Secretary of Health for the VA Healthcare System.

*Adapted from VA/ Department of Defense (DoD) Clinical Practice Guideline for Screening and Management of Overweight and Obesity (2014)

*Bolded names are members of the core-editing panel.

VA DODMichael Goldstein, MD Co-Chair Y. Sammy Choi, MD Co-Chair

Arianna Aoun, MS, RD, CSR, LD Raymond Batz, DO, MPHEdwin Gaar, MD Ronny Bigham, PA

Navjit Goraya, MD James Sebesta, MDGwen Hampton, RN Pennie Lou Pearson Hoofman, PhDSophia Hurley, MSPT Elizabeth Liebner, PTKenneth Jones, PhD Belinda Millner, RN

Todd Semla, MS, PharmD Theresa Newlin, FNP, FPC-BCCarol Volante, ARNP Connie Scott, MSM, RD

Robert Selvester, MDMaime Shell, RN-BC

Leilani Siaki, PhD, FNP-BCDarrell Zaugg, DO

Staff SupportCarla Cassidy, CRNP, MSN, M.Ed

M. Eric Rodgers, PhD, FNP, BC

Staff SupportErnest Degenhardt, MSN, FNP

Marjory Waterman, MN, RN

Lewin Group:

Erin Gardner Josie Idoko-Pean Anjali Jain, MD

Hillary Kleiner Sneha Rangarao Paul Wallace, MD


Appendix F

Methods and Instruments

Measures

These screenings should be routinely administered to patients as a regular part of their visits as part of the current VA clinical reminder system.

Body Mass Index Recording - BMI is calculated by dividing a person’s weight in kilograms by his or her height in meters squared. An adult with a BMI of 30 or greater is considered obese. (Obesity Action Coalition, 2015)

The Primary Care PTSD Screen (PC-PTSD) -The PC-PTSD is a 4-item screener that is designed to be used in the primary care setting. A screen is positive if an individual endorses a past trauma and symptoms from 2 of 4 domains: (1) re-experiencing, (2) avoidance, (3) hyperarousal, and (4) numbing/detachment. Each domain is assessed via a yes/no question. Scores were calculated and dichotomized into positive vs. negative. When using a cutoff of 2, the PC-PTSD has been found to have a sensitivity of 85% and a specificity of 76%. This tool has been used in similar studies with this population. (Gradus, 2014 )

Common Obesity-Associated Conditions screening:

•Hypertension

•Type 2 diabetes and pre-diabetes

•Dyslipidemia

•Metabolic syndrome

•Obstructive sleep apnea

•Degenerative joint disease

•Non-alcoholic fatty liver disease (VA/DoD, 2014)

Primary Instrument for Implementation

VA/ Department of Defense (DoD) Clinical Practice Guideline for Screening and

Management of Overweight and Obesity (2014)


Appendix G

Data Collection Tool

Data management is a large aspect of the VA system. There are various tools for

tracking and detecting the interventions required of veterans built into the Veterans Health

Information Systems and Technology Architecture (VISTA) data system used by the VA. As

the VA/DoD guideline points out, prompts will guide clinicians to perform specific

assessments (2014).

VISTA - Veterans Health Information Systems and Technology Architecture - is

VA's award winning Health Information Technology (IT) system. It provides an

integrated inpatient and outpatient electronic health record for VA patients, and

administrative tools to help VA deliver the best quality medical care to Veterans (VA,

2015).

o Allows nationwide access of medical records throughout all VA health care

facilities

o Provides a powerful teaching tool for all VA caregivers

o Provides data retrieval and reconciliation for specific conditions

o Correlates data and synthesizes into graphs for tracking


Appendix H

Project Budget

Budget Item Cost

Personnel:

Administrative Support Personnel (avg. one hour/wk x 52 weeks) @

$25/hr.

$1,300

Convening Board listed in Appendix E (32) – (avg. one hour/wk x 4

weeks) @ $50/hr.

$6,400

Educational Administrator to upload training materials in TMS (four

hours) @ $25/hr.

$100

Equipment:

Physical Manuscript copies for all VA facilities (optional) $10,000

TOTAL COST (including optional manuscripts) $17,800

TOTAL COST (excluding optional manuscripts) $7,800

evidence based research project final proposal

Documents