Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among veterans with mild traumatic brain injury.

STUDY OBJECTIVES:We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for co-morbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration (VHA). We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM. METHODS:Semi-structured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n=49). Clinical stakeholders included VHA providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder; obstructive sleep apnea [OSA]). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or OSA within the past year. Themes were identified using a Descriptive and Interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans. RESULTS:Barriers to implementing SDM were identified by both groups at the patient- (e.g., mTBI sequalae), provider- (e.g., de-prioritization of Veteran preferences), encounter- (e.g., time constraints), and facility-levels (e.g., reduced care access). Similarly, both groups identified facilitators at the patient- (e.g., enhanced trust), provider- (e.g., effective communication), encounter- (e.g., decision support), and facility-levels (e.g., mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively. CONCLUSIONS:Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for co-morbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes.