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Bakhai S, Mustafa J, Cloutier M, Islam F, Gudleski GD, Reynolds JL. Lean Six Sigma quality improvement approach to implement clinical practice guidelines for prescribing opiates for chronic pain in a primary care setting. BMJ Open Qual 2024; 13:e002912. [PMID: 39284680 PMCID: PMC11409372 DOI: 10.1136/bmjoq-2024-002912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 08/26/2024] [Indexed: 09/20/2024] Open
Abstract
BACKGROUND Implementing guidelines for chronic opioid management during a clinic merger posed significant challenges. Our aim was to increase the percentage of chronic pain evaluations and urine toxicology tests in patients on chronic opioid therapy from the baseline rate of less than 20% to 50% within 1 year at an academic, primary care clinic. METHODS We applied the Define, Measure, Analyze, Improve, Control (DMAIC) approach of Lean Six Sigma for this quality improvement (QI) project. The QI tools included the creation of stakeholder mapping, root cause analysis, process flow mapping and a driver diagram. Lack of patient and provider education emerged as a significant barrier. The outcome measures were percentage of chronic pain evaluations and urine drug toxicology with an increase in controlled substance agreement completion rates as our process measures. Major interventions included patient and provider education, leveraging health information technology, care coordination and implementing new clinic protocols. Data analysis was performed by monthly run charts. Descriptive statistics were used to summarise clinical variables, while χ2 analyses were employed to determine statistically significant differences between preintervention and postintervention measures. RESULTS We observed an increase in completion rates of clinic visits for chronic pain, rising from 19.0% to 51.9% (p<0.001). During study period, we observed a steady increase in chronic pain evaluations with a median of 4.5. Urine toxicology completion rates increased from 19.9% to 65.8% (p<0.001) during the preintervention and postintervention periods. We observed variable changes in urine toxicology rates with a median of 5.19. Furthermore, we observed an increase in controlled substance agreement completion rates, increasing to 50% from the baseline rate of <10%. CONCLUSIONS Education to patients and providers, shared decision-making using a patient-centred approach, enhancement of health information technology and system-based interventions in clinic protocols and workflows contributed to the success of this QI project. The DMAIC approach may facilitate the implementation of practice guidelines for chronic opioid therapy and enhance providers' opioid prescribing practices.
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Affiliation(s)
- Smita Bakhai
- Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Jawdat Mustafa
- Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Meghan Cloutier
- Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Farhana Islam
- Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Gregory D Gudleski
- University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Jessica L Reynolds
- Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
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Groessl EJ, Hafey C, McCarthy A, Hernandez RM, Prado-Nava M, Casteel D, McKinnon S, Chang DG, Ayers CR, Rutledge TR, Lang AJ, Bormann JE. Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2023; 12:27536130231220623. [PMID: 38152342 PMCID: PMC10752061 DOI: 10.1177/27536130231220623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Abstract
Background Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD. Methods In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions. Results The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue. Conclusions Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.
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Affiliation(s)
- Erik J. Groessl
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Carol Hafey
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Adhana McCarthy
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- US Army, San Antonio, TX, USA
| | - Rahil M. Hernandez
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Miguel Prado-Nava
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Danielle Casteel
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Symone McKinnon
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Douglas G. Chang
- Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of California San Diego, La Jolla, CA, USA
| | - Catherine R. Ayers
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Thomas R. Rutledge
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Ariel J. Lang
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Jill E. Bormann
- VA San Diego Healthcare System, San Diego, CA, USA
- Hahn School of Nursing and Health Sciences, Beyster Institute of Nursing Research, University of San Diego, San Diego, CA, USA
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Tilson JK, Martinez CA, MacDowell S, D’Silva LJ, Howard R, Roth HR, Skop KM, Dannenbaum E, Farrell L. Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series. BMC Health Serv Res 2022; 22:1462. [PMID: 36456945 PMCID: PMC9714412 DOI: 10.1186/s12913-022-08796-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 11/05/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND When a new guideline is published there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings. METHODS Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change. RESULTS Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location. CONCLUSIONS The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model. TRIAL REGISTRATION This study does not report the results of a health care intervention on human participants.
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Affiliation(s)
- Julie K. Tilson
- grid.42505.360000 0001 2156 6853Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California USA
| | - Clarisa A. Martinez
- grid.42505.360000 0001 2156 6853Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California USA
| | - Sara MacDowell
- grid.417320.30000 0000 9612 8770Physical Therapy, Hearing and Balance Center, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana USA
| | - Linda J. D’Silva
- grid.412016.00000 0001 2177 6375Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, Kansas USA
| | - Robbin Howard
- grid.42505.360000 0001 2156 6853Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California USA
| | - Heidi R. Roth
- grid.16753.360000 0001 2299 3507Northwestern University School of Physical Therapy and Human Movement Sciences and Shirley Ryan AbilityLab, Chicago, IL USA
| | - Karen M. Skop
- grid.170693.a0000 0001 2353 285XPhysical Medicine and Rehabilitation Services, Department of Physical Therapy, James A. Haley Veterans’ Hospital, Morsani College of Medicine, University of South Florida, School of Physical Therapy, Tampa, FL USA
| | - Elizabeth Dannenbaum
- grid.414993.20000 0000 8928 6420Vestibular Program, Jewish Rehabilitation Hospital Foundation, Laval, Quebec Canada
| | - Lisa Farrell
- Symmetry Alliance, LLC, Fort Lauderdale, Florida USA
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Corcoran KL, Peterson DR, Zhao X, Moran EA, Lisi AJ. Characteristics and productivity of the chiropractic workforce of the Veterans Health Administration. Chiropr Man Therap 2022; 30:18. [PMID: 35410303 PMCID: PMC8996387 DOI: 10.1186/s12998-022-00429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Increasingly, integrated healthcare systems such as the United States Veterans Health Administration (VHA) are employing chiropractors. However, little is known about chiropractor employee clinical productivity which may be important for resource planning and monitoring care delivery. With its history of delivering chiropractic care and its enterprise-level assessment metrics, the VHA is an ideal setting to study a chiropractic workforce. We aim to assess characteristics of chiropractors employed by the VHA and explore associations between these characteristics and clinical productivity. METHODS This was a cross-sectional and serial analyses of VHA administrative data. Characteristics of the chiropractor workforce were evaluated from fiscal year (FY) 2016 to FY2019. Productivity was calculated using the VHA productivity measure, the quotient of an individual's total work relative value units (wRVUs) per FY divided by the direct clinical full-time equivalent (FTE) worked. A multivariable regression model was used to analyze the association between productivity and characteristics of the chiropractor and VHA facility. RESULTS From FY2016 to FY2019, the number of chiropractor employees increased from 102 to 167. In FY2019, the typical chiropractor employee was male, white, and 45.9 years old with 5.2 years of VHA experience. In FY2019, the VHA chiropractor workforce was 25.1% female, 79% white, and 20.4% Veteran. The productivity measure of a chiropractor was 3040 in FY2019. A higher facility complexity measure, presence of 3 chiropractor employees at a facility, and older age of the providers were the only characteristics studied that had a significant impact on productivity after adjusting for other covariates. CONCLUSION Provider characteristics and productivity metrics of the VHA chiropractor employee workforce are presented. The productivity measure provides an initial benchmarking that may be relevant to future modeling of chiropractor personnel in VHA and other healthcare systems.
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Affiliation(s)
- Kelsey L. Corcoran
- grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidity and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA ,grid.47100.320000000419368710Yale Center for Medical Informatics, Yale School of Medicine, 300 George Street, New Haven, CT USA
| | - Douglas R. Peterson
- grid.413721.20000 0004 0419 317XOffice of Productivity, Efficiency and Staffing, VA Central Office, 810 Vermont Ave NW, Washington, DC USA
| | - Xiwen Zhao
- grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidity and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA ,grid.47100.320000000419368710Yale Center for Analytical Sciences, Yale School of Public Health, 300 George Street, New Haven, CT USA
| | - Eileen A. Moran
- grid.413721.20000 0004 0419 317XOffice of Productivity, Efficiency and Staffing, VA Central Office, 810 Vermont Ave NW, Washington, DC USA
| | - Anthony J. Lisi
- grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidity and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA ,grid.47100.320000000419368710Yale Center for Medical Informatics, Yale School of Medicine, 300 George Street, New Haven, CT USA
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Grant AD, Miller MM, Anastas TM, Quinn P, Lok B, Hirsh AT. Opioid-related risk perceptions in chronic pain: influence of patient gender and previous misuse behaviors. Pain 2022; 163:711-718. [PMID: 34285152 PMCID: PMC8761212 DOI: 10.1097/j.pain.0000000000002412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
ABSTRACT Little is known about the factors that influence providers' perceptions of patient risk for aberrant opioid use. Patient gender may interact with previous opioid misuse to influence these perceptions. We asked 131 physicians to view videos and vignettes for 8 virtual patients with chronic pain. Gender (male/female) and previous prescription opioid misuse (present/absent) varied across patients; the vignettes were otherwise balanced on demographic and clinical characteristics. For each patient, providers assessed 4 risk domains: opioid-related adverse events, opioid misuse or abuse, opioid addiction, and opioid diversion. Results indicated a significant gender-by-misuse interaction for risk of opioid misuse orabuse. When previous misuse behaviors were absent, providers rated men at higher risk; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid-related adverse events. Providers perceived men to be at higher risk when previous misuse behaviors were absent; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid addiction. Providers rated women at higher risk when previous misuse behaviors were present and men at higher risk when previous misuse behaviors were absent. There were significant main effects of gender and misuse for risk of opioid diversion. Providers rated men and those with previous misuse behaviors at higher risk. These results demonstrate that patient gender and previous opioid misuse have unique and interactive effects on provider perceptions of prescription opioid-related risks. Studies are needed to identify the mechanisms underlying these effects, such as gender-based stereotypes about risk-taking and drug abuse.
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Affiliation(s)
- Alexis D. Grant
- Department of Psychology, Indiana University-Purdue University Indianapolis
| | - Megan M. Miller
- Department of Psychology, Indiana University-Purdue University Indianapolis
| | - Tracy M. Anastas
- Department of Psychology, Indiana University-Purdue University Indianapolis
| | - Patrick Quinn
- School of Public Health, Indiana University Bloomington
| | - Benjamin Lok
- Department of Computer and Information Science and Engineering, University of Florida
| | - Adam T. Hirsh
- Department of Psychology, Indiana University-Purdue University Indianapolis
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Bolton R, Ritter G, Highland K, Larson MJ. The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System. BMC Health Serv Res 2022; 22:312. [PMID: 35255912 PMCID: PMC8900315 DOI: 10.1186/s12913-022-07700-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain – Army soldiers returning from deployment. Methods Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008–2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures. Results In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care. Conclusions Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07700-4.
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Affiliation(s)
- Rendelle Bolton
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA. .,US Department of Veterans Affairs, VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, 200 Springs Road, Bedford, MA, 01730, USA.
| | - Grant Ritter
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
| | - Krista Highland
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA.,Henry M. Jackson Foundation, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA
| | - Mary Jo Larson
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
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Pierce RP, Eskridge B, Ross B, Wright M, Selva T. Impact of a Vendor-Developed Opioid Clinical Decision Support Intervention on Adherence to Prescribing Guidelines, Opioid Prescribing, and Rates of Opioid-Related Encounters. Appl Clin Inform 2022; 13:419-430. [PMID: 35445387 PMCID: PMC9021002 DOI: 10.1055/s-0042-1745830] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/18/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Provider prescribing practices contribute to an excess of opioid-related deaths in the United States. Clinical guidelines exist to assist providers with improving prescribing practices and promoting patient safety. Clinical decision support systems (CDSS) may promote adherence to these guidelines and improve prescribing practices. The aim of this project was to improve opioid guideline adherence, prescribing practices, and rates of opioid-related encounters through the implementation of an opioid CDSS. METHODS A vendor-developed, provider-targeted CDSS package was implemented in a multi-location academic health center. An interrupted time-series analysis was performed, evaluating 30 weeks pre- and post-implementation time periods. Outcomes were derived from vendor-supplied key performance indicators and directly from the electronic health record (EHR) database. Opioid-prescribing outcomes included count of opioid prescriptions, morphine milligram equivalents per prescription, counts of opioids with concurrent benzodiazepines, and counts of short-acting opioids in opioid-naïve patients. Encounter outcomes included rates of encounters for opioid abuse and dependence and rates of encounters for opioid poisoning and overdose. Guideline adherence outcomes included rates of provision of naloxone and documentation of opioid treatment agreements. RESULTS The opioid CDSS generated an average of 1,637 alerts per week. Rates of provision of naloxone and opioid treatment agreements improved after CDSS implementation. Vendor-supplied prescribing outcomes were consistent with prescribing outcomes derived directly from the EHR, but all prescribing and encounter outcomes were unchanged. CONCLUSION A vendor-developed, provider-targeted opioid CDSS did not improve opioid-prescribing practices or rates of opioid-related encounters. The CDSS improved some measures of provider adherence to opioid-prescribing guidelines. Further work is needed to determine the optimal configuration of opioid CDSS so that opioid-prescribing patterns are appropriately modified and encounter outcomes are improved.
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Affiliation(s)
- Robert P. Pierce
- Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, Missouri, United States
| | - Bernie Eskridge
- Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri, United States
| | - Brandi Ross
- Tiger Institute, Cerner Corporation, Columbia, Missouri, United States
| | - Matthew Wright
- University of Missouri Health Care, Columbia, Missouri, United States
| | - Thomas Selva
- Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri, United States
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Johnson A, Booker SQ. Population-Focused Approaches for Proactive Chronic Pain Management in Older Adults. Pain Manag Nurs 2021; 22:694-701. [PMID: 33972196 PMCID: PMC11198878 DOI: 10.1016/j.pmn.2021.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/14/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022]
Abstract
Chronic pain, and the ethical management thereof, is the single most imperative health issue of this decade. Although a growing majority of individuals with chronic pain are middle-aged, the largest proportion of sufferers are older adults. Shifting tides in practice and research have led to population-focused approaches to pain management; however, the practice of many healthcare providers remains reactive and individualistic, limiting the discovery and implementation of long-term solutions for pain management in older adults. Yet, nurses and other health professionals have an opportune position to provide expert pain care by proactively providing evidence-based care for patients systematically. The purpose of this article is to stimulate discussion on three paradigms important to population-focused pain management: (1) prevention; (2) restoration and rehabilitation; and (3) palliation, which are in line with current national policy initiatives for improving patients' care experience, improving overall health and quality of life, and reducing associated health care costs.
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Affiliation(s)
- Alisa Johnson
- Pain Research and Intervention Center of Excellence, College of Dentistry, University of Florida, Gainesville, Florida.
| | - Staja Q Booker
- Pain Research and Intervention Center of Excellence, College of Dentistry, University of Florida, Gainesville, Florida; College of Nursing, University of Florida, Gainesville, Florida
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Chopra D, Li C, Painter JT, Bona JP, Nookaew I, Martin BC. Characteristics and Network Influence of Providers Involved in the Treatment of Patients With Chronic Back, Neck or Joint Pain in Arkansas. THE JOURNAL OF PAIN 2021; 22:1681-1695. [PMID: 34174385 DOI: 10.1016/j.jpain.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
Increasing emphasis on guidelines and prescription drug monitoring programs highlight the role of healthcare providers in pain treatment. Objectives of this study were to identify characteristics of key players and influence of opioid prescribers through construction of a referral network of patients with chronic pain. A retrospective cohort study was performed and patients with commercial or Medicaid coverage with chronic back, neck, or joint pain were identified using the Arkansas All-Payer Claims-Database. A social network comprised of providers connected by patient referrals based on 12-months of healthcare utilization following chronic pain was constructed. Network measures evaluated were indegree and eigen (referrals obtained), betweenness (involvement), and closeness centrality (reach). Outcomes included influence of providers, opioid prescribers, and brokerage status. Exposures included provider demographics, specialties and network characteristics. There were 51,941 chronic pain patients who visited 8,110 healthcare providers. Primary care providers showed higher betweenness and closeness whereas specialists had higher indegree. Opioid providers showed higher centrality compared to non-opioid providers, which decreased with increasing volume of opioid prescribing. Non-pharmacologic providers showed significant brokerage scores. Findings from this study such as primary care providers having better reach, non-central positions of high-volume prescribers and non-pharmacologic providers having higher brokerage can aid interventional physician detailing. PERSPECTIVE: Opioid providers held central positions in the network aiding provider-directed interventions. However, high-volume opioid providers were at the borders making them difficult targets for interventions. Primary care providers had the highest reach, specialists received the most referrals and non-pharmacological providers and specialists acted as brokers between non-opioid and opioid prescribers.
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Affiliation(s)
- Divyan Chopra
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jacob T Painter
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jonathan P Bona
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock Arkansas
| | - Intawat Nookaew
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock Arkansas
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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Kwon E, Stange C, Reichlin K, Vernon H, Miyanari A, Bier E, Beydoun H, Kalish V. A Comprehensive, Multimodal, Interdisciplinary Approach to Chronic Non-Cancer Pain Management in a Family Medicine Clinic: A Retrospective Cohort Review. Perm J 2021; 25:20.307. [PMID: 35348080 PMCID: PMC8784064 DOI: 10.7812/tpp/20.307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 07/20/2021] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The complexity of chronic non-cancer pain in the setting of regulatory efforts to curb opioid usage presents a novel challenge for the medical community. Much of this burden falls on primary care clinics. We retrospectively quantified the reduction of opioid usage by patients in a multimodal, interdisciplinary, primary care clinic for chronic pain. METHODS A multimodal, interdisciplinary, chronic pain clinic embedded in a large academic military family medicine clinic operated one-half day weekly to address referrals from within the clinic at large. Appointment times were longer than typical primary care appointments. The clinic was equipped with support staff, ancillary specialty providers, and non-pharmacologic complementary treatment resources. A retrospective cohort review was conducted on 78 patients referred to this clinic from March 1, 2015 (the inception date of the clinic) through December 31, 2015. RESULTS Fifty-four of 78 patients met inclusion criteria. Overall mean morphine equivalent daily dosing (MEDD) dropped from 31.5 MEDD to 20.5 MEDD (p = 0.0005) 12 months post-intervention and from 31.5 MEDD to 9.5 MEDD (p < 0.0001) 36 months post-intervention. Four patients with a high mean baseline opioid dose of 185.2 MEDD dropped to 29.9 MEDD 36 months post-intervention. The mean 0-10 pain score decreased from 5.3 ± 2.2 to 4.0 ± 2.5 (p = 0.001). CONCLUSION A multimodal, interdisciplinary, primary care-based, chronic pain clinic equipped with extended appointment times, non-pharmacologic treatment resources, and specialty access can curb opioid usage. Leadership support for protracted appointment duration, complementary treatment resources, and interdisciplinary personnel is crucial to success.
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Affiliation(s)
- Edward Kwon
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Christopher Stange
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Katy Reichlin
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Hamilton Vernon
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Akira Miyanari
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Elizabeth Bier
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Hind Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Virginia Kalish
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA
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11
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Coleman BC, Goulet JL, Higgins DM, Bathulapalli H, Kawecki T, Ruser CB, Bastian LA, Martino S, Piette JD, Edmond SN, Heapy AA. ICD-10 Coding of Musculoskeletal Conditions in the Veterans Health Administration. PAIN MEDICINE 2021; 22:2597-2603. [PMID: 33944953 DOI: 10.1093/pm/pnab161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE We describe the most frequently used musculoskeletal diagnoses in Veterans Health Administration (VHA) care. We report the number of visits and patients associated with common musculoskeletal ICD-10 codes and compare trends across primary and specialty care settings. DESIGN Secondary analysis of a longitudinal cohort study. SUBJECTS Veterans included in the Musculoskeletal Diagnosis Cohort with a musculoskeletal diagnosis from October 1, 2015 through September 30, 2017. METHODS We obtained counts and proportions of all musculoskeletal diagnosis codes used and the number of unique patients with each musculoskeletal diagnosis. Diagnosis use was compared between primary and specialty care settings. RESULTS Of over 6,400 possible ICD-10 M-codes describing "Diseases of the Musculoskeletal System and Connective Tissue", 5,723 codes were used at least once. The most frequently used ICD-10 M-code was "Low Back Pain" (18.3%) followed by "Cervicalgia" (3.6%). Collectively, the 100 most frequently used codes accounted for 80% of M-coded visit diagnoses, and 95% of patients had at least one of these diagnoses. The most common diagnoses (spinal pain, joint pain, osteoarthritis) were used similarly in primary and specialty care settings. CONCLUSION A diverse sample of all available musculoskeletal diagnosis codes were used; however, less than 2% of all possible codes accounted for 80% of the diagnoses used. This trend was consistent across primary and specialty care settings. The most frequently used diagnosis codes describe the types of musculoskeletal conditions, among a large pool of potential diagnoses, that prompt veterans to present to VHA for musculoskeletal care.
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Affiliation(s)
- Brian C Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Diana M Higgins
- Anesthesiology, Critical Care, and Pain Medicine Service, VA Boston Healthcare System, Boston, MA.,Boston University School of Medicine, Boston, MA
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Todd Kawecki
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Christopher B Ruser
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Steve Martino
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - John D Piette
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.,University of Michigan School of Public Health, Ann Arbor, MI
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Alicia A Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
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12
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Vogel E, Mior SA, Sutton D, Côté P, French S, Nordin M, Laporte A. When boundaries blur - exploring healthcare providers' views of chiropractic interprofessional care and the Canadian Forces Health Services. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2021; 65:14-31. [PMID: 34035538 PMCID: PMC8128330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Musculoskeletal (MSK) conditions are primary reasons prohibiting Canadian Armed Forces (CAF) personnel from being deployed, with back pain the second most common activity-limiting condition. CAF provides a spectrum of services, including chiropractic care. There is a paucity of data related to chiropractic interprofessional care (IPC) within CAF healthcare settings. METHODS A qualitative study, using an Interpretative Phenomenological Analysis (IPA) approach, involving 25 key informant interviews explored factors that impact chiropractic IPC. We used a systematic but not prescriptive process, based on a thematic analysis, to interconnect data to develop meaning and explanation. Initially, we explained and interpreted participant's experiences and meanings. Next, we used extant literature and theory, together with expert knowledge, to explain and interpret the meanings of participants' shared accounts. RESULTS We present findings central to the domain, Role Clarity, as described in the IPC Competency Framework. Our findings call for strengthening IPC specific to MSK conditions in the CAF, including an examination of gatekeeping roles, responsibilities and outcomes. CONCLUSION It is timely to investigate models of care that nurture and sustain inter-provider relationships in planning and coordinating evidence-based chiropractic care for MSK conditions, within the CAF, and its extended referral networks.
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Affiliation(s)
- Ellen Vogel
- Faculty of Health Sciences, Ontario Tech University
| | - Silvano A Mior
- Canadian Memorial Chiropractic College
- Centre for Disability Prevention and Rehabilitation at Ontario Tech University and Canadian Memorial Chiropractic College
- Institute of Health Policy Management and Evaluation, University of Toronto
| | | | - Pierre Côté
- Faculty of Health Sciences, Ontario Tech University
- Centre for Disability Prevention and Rehabilitation at Ontario Tech University and Canadian Memorial Chiropractic College
- Institute of Health Policy Management and Evaluation, University of Toronto
| | - Simon French
- Department of Chiropractic, Macquarie University
| | - Margareta Nordin
- Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Centre (OIOC), New York University
| | - Audrey Laporte
- Institute of Health Policy Management and Evaluation, University of Toronto
- Canadian Centre for Health Economics
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13
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Adherence to Stepped Care for Management of Musculoskeletal Knee Pain Leads to Lower Health Care Utilization, Costs, and Recurrence. Am J Med 2021; 134:351-360.e1. [PMID: 32931762 DOI: 10.1016/j.amjmed.2020.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/04/2020] [Accepted: 08/22/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study aimed to report compliance with stepped care management of patellofemoral pain and determine whether adherence to stepped care results in decreased recurrence and lower health care utilization. METHODS A total of 60,730 participants were included, using data from the Military Health System Data Repository, a large single-payer government health system. Outcomes included total knee-related care visits and costs, knee surgeries, opioid prescriptions, and 2-year recurrence. Stepped care was based on interventions delivered within the appropriate timing and in the appropriate order (low risk/cost before high risk/cost). RESULTS A total of 54,460 (89.7%) participants received adherent Step 1 care, 10,964 (18.1%) received step 2, and 4168 (6.9%) received step 3. A total of 32.0% and 50.8%, respectively, of all patients in Step 2 and Step 3 care were adherent. Of the 2385 participants (3.9% of cohort) that received both Step 2 and Step 3 care, 24.8% of participants received adherent care. For participants receiving both Step 2 and Step 3 care, adherence resulted in cost savings (mean difference [MD] $1708; 95% confidence interval [CI]: $1241, 2175), fewer knee-related visits (MD 3.4; 95% CI 2.2, 4.7), fewer episodes of knee pain (MD 0.7; 95% CI 0.5, 0.8), fewer knee surgeries (adjusted odds ratio 0.4; 95% CI 0.3, 0.5), and fewer opioid prescriptions (adjusted odds ratio 0.6; 95% CI 0.5, 0.8). CONCLUSION These findings demonstrate the value of following stepped care guidelines for pain management in patients with patellofemoral pain.
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14
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Corcoran KL, Bastian LA, Gunderson CG, Steffens C, Brackett A, Lisi AJ. Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis. PAIN MEDICINE 2021; 21:e139-e145. [PMID: 31560777 DOI: 10.1093/pm/pnz219] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate the current evidence to determine if there is an association between chiropractic use and opioid receipt. DESIGN Systematic review and meta-analysis. METHODS The protocol for this review was registered on PROSPERO (CRD42018095128). The MEDLINE, PubMed, EMBASE, AMED, CINAHL, and Web of Science databases were searched for relevant articles from database inception through April 18, 2018. Controlled studies, cohort studies, and case-control studies including adults with noncancer pain were eligible for inclusion. Studies reporting opioid receipt for both subjects who used chiropractic care and nonusers were included. Data extraction and risk of bias assessment were completed independently by pairs of reviewers. Meta-analysis was performed and presented as an odds ratio with 95% confidence interval. RESULTS In all, 874 articles were identified. After detailed selection, 26 articles were reviewed in full, and six met the inclusion criteria. Five studies focused on back pain and one on neck pain. The prevalence of chiropractic care among patients with spinal pain varied between 11.3% and 51.3%. The proportion of patients receiving an opioid prescription was lower for chiropractic users (range = 12.3-57.6%) than nonusers (range = 31.2-65.9%). In a random-effects analysis, chiropractic users had a 64% lower odds of receiving an opioid prescription than nonusers (odds ratio = 0.36, 95% confidence interval = 0.30-0.43, P < 0.001, I2 = 92.8%). CONCLUSIONS This review demonstrated an inverse association between chiropractic use and opioid receipt among patients with spinal pain. Further research is warranted to assess this association and the implications it may have for case management strategies to decrease opioid use.
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Affiliation(s)
- Kelsey L Corcoran
- Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Craig G Gunderson
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Catherine Steffens
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Anthony J Lisi
- Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
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15
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Husebo BS, Kerns RD, Han L, Skanderson M, Gnjidic D, Allore HG. Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration. Brain Sci 2021; 11:86. [PMID: 33440668 PMCID: PMC7827274 DOI: 10.3390/brainsci11010086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.
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Affiliation(s)
- Bettina S. Husebo
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Municipality of Bergen, 5020 Bergen, Norway
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT 06511, USA;
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Ling Han
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Danijela Gnjidic
- Charles Perkins Centre, Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney 2006 NSW, Australia;
| | - Heather G. Allore
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT 06511, USA
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16
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Shen Y, Bhagwandass H, Branchcomb T, Galvez SA, Grande I, Lessing J, Mollanazar M, Ourhaan N, Oueini R, Sasser M, Valdes IL, Jadubans A, Hollmann J, Maguire M, Usmani S, Vouri SM, Hincapie-Castillo JM, Adkins LE, Goodin AJ. Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions. THE JOURNAL OF PAIN 2020; 22:246-262. [PMID: 33031943 DOI: 10.1016/j.jpain.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/24/2023]
Abstract
The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.
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Affiliation(s)
- Yun Shen
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Hemita Bhagwandass
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Tychell Branchcomb
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Sophia A Galvez
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivanna Grande
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Julia Lessing
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Mikela Mollanazar
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Natalie Ourhaan
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Razanne Oueini
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Sasser
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ashmita Jadubans
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Josef Hollmann
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Maguire
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Silken Usmani
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida; Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Lauren E Adkins
- University of Florida Health Science Center Libraries, Gainesville, Florida
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida.
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17
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Shoemaker-Hunt SJ, Evans L, Swan H, Bacon O, Ike B, Baldwin LM, Parchman ML. Study protocol for evaluating Six Building Blocks for opioid management implementation in primary care practices. Implement Sci Commun 2020; 1:16. [PMID: 32885178 PMCID: PMC7427954 DOI: 10.1186/s43058-020-00008-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background The Six Building Blocks for improving opioid management (6BBs) is a program for improving the management of patients in primary care practices who are on long-term opioid therapy for chronic pain. The 6BBs include building leadership and consensus; aligning policies, patient agreements, and workflows; tracking and monitoring patient care; conducting planned, patient-centered visits; tailoring care for complex patients; and measuring success. The Agency for Healthcare Research and Quality funded the development of a 6BBs implementation guide: a step-by-step approach for independently implementing the 6BBs in a practice. This mixed-method study seeks to assess practices’ use of the implementation guide to implement the 6BBs and the effectiveness of 6BBs implementation on opioid management processes of care among practices using the implementation guide. Methods Data collection is guided by the Consolidated Framework for Implementation Research, Proctor’s taxonomy of implementation outcomes, and the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain. A diverse group of health care organizations with primary care clinics across the USA will participate in the study over 15 months. Qualitative data collection will include semi-structured interviews with stakeholders at each organization at two time points, notes from routine check-in calls, and document review. These data will be used to understand practices’ motivation for participation, history with opioid management efforts, barriers and facilitators to implementation, and implementation progress. Quantitative data collection will consist of a provider and staff survey, an implementation milestones assessment, and quarterly opioid prescribing quality measures. These data will supplement our understanding of implementation progress and will allow us to assess changes over time in providers’ opioid prescribing practices, prescribing self-efficacy, challenges to providing guideline-driven care, and practices’ opioid prescribing quality measures. Qualitative data will be coded and analyzed for emergent themes. Quantitative data will be analyzed using descriptive statistics and clustered multivariate regression. Discussion This study contributes to the knowledge of the implementation and effectiveness of a team-based approach to opioid management in primary care practices. Information gleaned from this study can be used to inform efforts to curtail opioid prescribing and assist primary care practices considering implementing the 6BBs.
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Affiliation(s)
| | - Leigh Evans
- Division of Health and Environment, Abt Associates, Inc., Cambridge, USA
| | - Holly Swan
- Division of Health and Environment, Abt Associates, Inc., Cambridge, USA
| | - Olivia Bacon
- Division of Health and Environment, Abt Associates, Inc., Cambridge, USA
| | - Brooke Ike
- Department of Family Medicine, University of Washington, Seattle, USA
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, USA
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18
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Hadlandsmyth K, Mosher HJ, Bayman EO, Wikle JG, Lund BC. A Typology of New Long-term Opioid Prescribing in the Veterans Health Administration. J Gen Intern Med 2020; 35:2607-2613. [PMID: 32206994 PMCID: PMC7458960 DOI: 10.1007/s11606-020-05749-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/31/2020] [Accepted: 02/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Narrow definitions of long-term opioid (LTO) use result in limited knowledge of the full range of LTO prescribing patterns and the rates of these patterns. OBJECTIVE To investigate a model of new LTO prescribing typologies using latent class analysis. DESIGN National administrative data from the VA Corporate Data Warehouse were accessed using the VA Informatics and Computing Infrastructure. Characterization of the typology of initial LTO prescribing was explored using latent class analysis. PARTICIPANTS Veterans initiating LTO during 2016 through the Veteran's Administration Healthcare System (N = 42,230). MAIN MEASURES Opioid receipt as determined by VA prescription data, using the cabinet supply methodology. KEY RESULTS Over one-quarter (27.7%) of the sample fell into the fragmented new long-term prescribing category, 39.8% were characterized by uniform daily new LTO, and the remaining 32.7% were characterized by uniform episodic LTO. Each of these three broad sub-groups also included two additional sub-groups (6 classes total in the model), characterized by the presence or absence of prior opioid prescriptions. CONCLUSIONS New LTO prescribing in the VA includes uniform daily prescribing, uniform episodic prescribing, and fragmented prescribing. Future work is needed to elucidate the safety and efficacy of these prescribing patterns.
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Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Hilary J Mosher
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Emine O Bayman
- University of Iowa, College of Public Health, Iowa City, IA, USA
| | - Justin G Wikle
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
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19
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Weller LM. Development and implementation of a primary care clinic workflow protocol to meet opioid prescribing guidelines. J Am Assoc Nurse Pract 2020; 33:1100-1107. [PMID: 32804807 DOI: 10.1097/jxx.0000000000000487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nearly 50% of opioid overdose deaths in the United States involve the use of prescription opioids. Primary care providers can help decrease the risk of opioid overdose deaths by adhering to opioid prescribing guidelines for chronic pain management. LOCAL PROBLEM Ten Washington State primary care clinics had gaps in guideline adherence and mandated electronic medical record (EMR) documentation for prescribing opioids. METHODS A quality improvement project using an educational intervention was implemented. INTERVENTIONS Primary care providers and support staff (defined as registered nurses and medical assistants) from the 10 primary care clinics viewed the project's instructional YouTube webinar that explained the project's primary care clinic workflow protocol, opioid prescribing best practice guidelines, and the organization's mandated EMR charting for chronic pain management. Preintervention and postintervention measures, which included five different documented patient completion rates of the organization's best practices for opioid prescribing, were used to assess for improvement to guideline adherence. Additionally, participants completed a questionnaire regarding their perceptions of the webinar as an educational tool. RESULTS Postintervention data showed significantly (p ≤ .05) increased completion rates for three of five outcome measures, indicating improvement in guideline adherence. The majority of participants reported that the webinar information would help them better adhere to best practice guidelines. CONCLUSIONS A workflow protocol for opioid prescribing taught via a YouTube webinar was an effective method for disseminating and implementing best practices in the primary care setting. Similar workflow protocols, taught via webinar, could be equally beneficial in other primary care clinics.
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Affiliation(s)
- Lori M Weller
- Pacific Lutheran University, School of Nursing, Tacoma, Washington
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Holtrop JS, Fisher M, Martinez DE, Simpson M, Awadallah NS, Nease DE, Zittleman L, Westfall JM. What Works for Managing Chronic Pain: An Appreciative Inquiry Qualitative Analysis. J Prim Care Community Health 2020; 10:2150132719885286. [PMID: 31747822 PMCID: PMC6873267 DOI: 10.1177/2150132719885286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Chronic pain is a prevalent and dynamic condition for
both patients and providers. Learning how patients with chronic pain
successfully manage their pain may prove helpful in guiding health care
providers in their treatment of other patients with chronic pain. This research
sought to identify successful strategies for managing chronic pain from
interviews with individuals experiencing chronic pain who were able to do “most
of what they want on most days.” Methods: Qualitative, descriptive
study. Patients were from metro Denver, Colorado, USA and were recruited from
community and health care settings. Appreciative inquiry (AI) was used as an
approach to elicit stories of successful pain management. We conducted
one-on-one, in person interviews using a semistructured interview guide.
Analysis was completed using a grounded hermeneutic editing approach.
Results: Twenty-four interviews were completed representing a
range of adult ages, genders, race/ethnicities, and underlying reasons for
chronic pain. Consistent themes were found in that all patients had developed
multiple strategies for ongoing pain management and prevention, as well as a
mental approach embedded with elements of positive beliefs and determination.
Friends, family, support group members, and health care providers were key in
support and ongoing management. Although 10 patients regularly used opioid pain
medications, none were dependent, and all stated an active desire to avoid these
medications. Conclusions: Successful chronic pain management seems
possible as displayed from the patient narratives but requires persistence
through individual trial and error. Recommendations for health care provider
teams are made to apply these findings to assist patients with chronic pain.
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Affiliation(s)
| | - Mary Fisher
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | | | - Matthew Simpson
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Nida S Awadallah
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Donald E Nease
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Linda Zittleman
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - John M Westfall
- University of Colorado Denver School of Medicine, Aurora, CO, USA
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21
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Kerns RD, Brandt CA, Peduzzi P. NIH-DoD-VA Pain Management Collaboratory. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:2336-2345. [PMID: 31807788 PMCID: PMC6895460 DOI: 10.1093/pm/pnz186] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Robert D Kerns
- VA Connecticut Healthcare System, West Haven, Connecticut
| | | | - Peter Peduzzi
- Yale University School of Medicine, New Haven, Connecticut, USA
- Please see the Appendix for the complete list of authors and affiliations
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22
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Oldfield BJ, Edens EL, Agnoli A, Bone CW, Cervone DJ, Edmond SN, Manhapra A, Sellinger JJ, Becker WC. Multimodal Treatment Options, Including Rotating to Buprenorphine, Within a Multidisciplinary Pain Clinic for Patients on Risky Opioid Regimens: A Quality Improvement Study. PAIN MEDICINE 2019; 19:S38-S45. [PMID: 30203007 DOI: 10.1093/pm/pny086] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain-the Opioid Reassessment Clinic (ORC)-to inform practice and health system improvement. Design Controlled, retrospective cohort study. Setting The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Subjects We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group). Methods We compared a priori-defined metrics at the patient, clinic process, and health system levels and compared metrics between groups. Results During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0-120] vs 0 mg [IQR = 0-20] decrease, P < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP. Conclusions Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed.
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Affiliation(s)
- Benjamin J Oldfield
- VA Connecticut Health Care System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut.,National Clinician Scholars Program, New Haven, Connecticut
| | - Ellen L Edens
- VA Connecticut Health Care System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Alicia Agnoli
- University of California, Davis, Sacramento, California
| | - Curtis W Bone
- VA Connecticut Health Care System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Dana J Cervone
- VA Connecticut Health Care System, West Haven, Connecticut
| | - Sara N Edmond
- VA Connecticut Health Care System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Ajay Manhapra
- Yale School of Medicine, New Haven, Connecticut.,VA Hampton Medical Center, Hampton, Virginia, USA
| | - John J Sellinger
- VA Connecticut Health Care System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - William C Becker
- VA Connecticut Health Care System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
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23
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Edmond SN, Moore BA, Dorflinger LM, Goulet JL, Becker WC, Heapy AA, Sellinger JJ, Lee AW, Levin FL, Ruser CB, Kerns RD. Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management. PAIN MEDICINE 2019; 19:S30-S37. [PMID: 30203015 DOI: 10.1093/pm/pny094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. Design An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Subjects Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). Methods We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. Results We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Conclusions Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.
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Affiliation(s)
- Sara N Edmond
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Brent A Moore
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Lindsey M Dorflinger
- Health Psychology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Emergency Medicine
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alicia A Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - John J Sellinger
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Allison W Lee
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Forrest L Levin
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher B Ruser
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry.,Departments of Neurology and Psychology, Yale University, New Haven, Connecticut, USA
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24
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Becker WC, Edmond SN, Cervone DJ, Manhapra A, Sellinger JJ, Moore BA, Edens EL. Evaluation of an Integrated, Multidisciplinary Program to Address Unsafe Use of Opioids Prescribed for Pain. PAIN MEDICINE 2019; 19:1419-1424. [PMID: 28371816 DOI: 10.1093/pm/pnx041] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objectives Unsafe use of opioids prescribed for pain is a common challenge in primary care. We aimed to describe a novel clinical program designed to address this issue-the Opioid Reassessment Clinic-and evaluate preliminary efficacy. Methods The Opioid Reassessment Clinic is a multidisciplinary care team staffed by an internist, addiction psychiatrist, advanced practice nurse, and health psychologist designed to perform enhanced assessment and longitudinal treatment of patients with unsafe use of opioids prescribed for pain. We assessed preliminary efficacy of the clinic using a priori-defined metrics at the patient, provider, clinic process, and health system levels. Results Of referred patients (N = 87), 84% had a history of substance abuse/dependence and 70% had current misuse of prescribed opioids; 22% received a new substance use disorder diagnosis, each of whom engaged in addiction treatment. Among primary care physicians, 48% referred a patient to the clinic. In terms of process metrics, high fidelity to structured clinical assessments was assisted by templated electronic progress notes. Wait time averaged 22.1 days while length of treatment averaged 137 days. Urine drug testing was performed on 91% of patients an average of 6.4 times, while assessing out-of-system opioid receipt occurred universally. Systems-level findings included evidence of institutional support: hiring a nurse case manager to help with care coordination. Conclusions Results suggest the Opioid Reassessment Clinic was effective in the management of a small group of high-complexity patients. Wide-scale dissemination may require adapted care models.
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Affiliation(s)
- William C Becker
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sara N Edmond
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dana J Cervone
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Ajay Manhapra
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut, USA
| | - John J Sellinger
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brent A Moore
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ellen L Edens
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut, USA
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25
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Jones LK, Lussier ME, Brar J, Byrne MC, Durham M, Kiokemeister F, Kjaer K, Le H, Magee C, McKnight E, Mehta N, Papp J, Pastwa E, Radovich P, Ravin K, Ruther M, Woodie G, Wrona S, Yousefvand G, Greskovic G. Current interventions to promote safe and appropriate pain management. Am J Health Syst Pharm 2019; 76:829-834. [PMID: 31415689 DOI: 10.1093/ajhp/zxz063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Describe patient-, clinician-, system-, and community-level interventions for pain management developed and employed by 9 healthcare systems across the United States and report on lessons learned from the implementation of these interventions. SUMMARY The high cost associated with pain coupled with the frequent use of opioid analgesics as primary treatment options has made novel pain management strategies a necessity. Interventions that target multiple levels within healthcare are needed to help combat the opioid epidemic and improve strategies to manage chronic pain. Patient-level interventions implemented ranged from traditional paper-based educational tools to videos, digital applications, and peer networks. Clinician-level interventions focused on providing education, ensuring proper follow-up care, and establishing multidisciplinary teams that included prescribers, pharmacists, nurses, and other healthcare professionals. System- and community-level interventions included metric tracking and analytics, electronic health record tools, lockbox distribution for safe storage, medication return bins for removal of opioids, risk assessment tool utilization, and improved access to reversal agents. CONCLUSION Strategies to better manage pain can be implemented within health systems at multiple levels and on many fronts; however, these changes are most effective when accepted and widely used by the population for which they are targeted.
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Affiliation(s)
- Laney K Jones
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Mia E Lussier
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA
| | - Jasmit Brar
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Mary C Byrne
- Department of Pharmacy, Tuba City Regional Health Care Corporation, Tuba City, AZ
| | - Melissa Durham
- Titus Family Department of Clinical Pharmacy, USC School of Pharmacy, Los Angeles, CA
| | | | - Klaus Kjaer
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Huy Le
- Pharmacy Department, Loma Linda University Medical Center, Loma Linda, CA
| | - Chelsea Magee
- Pharmacy, Penobscot Community Health Care, Bangor, ME
| | - Erin McKnight
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Neel Mehta
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Joan Papp
- Department of Emergency Medicine, MetroHealth, Cleveland, OH
| | | | - Patti Radovich
- Nursing Research Department, Loma Linda University Medical Center, Loma Linda, CA
| | | | - Michelle Ruther
- Clinical Effectiveness, Advocate Aurora Healthcare, Downers Grove, IL
| | - Gloriana Woodie
- Mental Health, Tuba City Regional Health Care Corporation, Tuba City, AZ
| | - Sharon Wrona
- Comprehensive Pain and Palliative Care Services, Nationwide Children's Hospital, Columbus, OH
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26
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Mior SA, Vogel E, Sutton D, French S, Côté P, Nordin M, Loisel P, Laporte A. Exploring Chiropractic Services in the Canadian Forces Health Services - Perceptions of Facilitators and Barriers Among Key Informants. Mil Med 2019; 184:e344-e351. [PMID: 30462275 DOI: 10.1093/milmed/usy319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/16/2018] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Musculoskeletal (MSK) conditions have a significant impact on the health and operational readiness of military members. The Canadian Forces Health Services (CFHS) provides a spectrum of health services in managing Canadian Armed Forces (CAF) personnel health care needs with on-base and off-base services provided by civilian and uniformed health care professionals, including chiropractors. Although chiropractic services are available in US DoD and VA systems, little is known about the facilitators and barriers to integrating on-base chiropractic services within the CFHS. This study explored key informants' perceptions of facilitators and barriers to the integration of on-base chiropractic services within the CFHS. METHODS We conducted a qualitative study to describe and understand how an integrated chiropractic service could be designed, implemented, and evaluated within the current interdisciplinary CFHS. Telephone interviews were conducted, using a semi-structured interview guide, to explore key informants' perceptions and experiences of chiropractic care within the CFHS. In total, we invited 27 individuals across Canada to participate; 15 were identified through purposeful sampling, 12 through a snowball sampling technique, and 2 declined. The 25 participants included military personnel (52%), public servants and contractors employed by the Department of Defense (24%), as well as civilian health care providers (24%). All participants were health care providers [physicians (MD) (7), physiotherapists (PT) (13), chiropractors (DC) (5)]. Interviews were audio-recorded and transcribed verbatim. Transcripts were prepared and analyzed using an interpretivist approach that explored key informants' perceptions and experiences. RESULTS Qualitative analysis revealed numerous facilitators and barriers to chiropractic services in the CFHS. These were categorized under three broad themes: base-to-base variations, variable gatekeeper roles, and referral processes. Barriers to integrating chiropractic services included: lack of clarity about a chiropractor's clinical knowledge and skills; CFHS team members' negative prior experiences with chiropractors (e.g., inappropriate patient-focused communication, clinical management that was not evidence-based, ignorance of military culture); suboptimal bi-directional communication between CAF personnel and DCs across bases; and wide-ranging perspectives pertaining to duplication of services offered by PTs and DCs in managing MSK conditions. Facilitators associated with the integration of chiropractic services within a collaborative and interdisciplinary CAF environment included: patient benefits associated with multiple approaches utilized by different providers; adoption of up-to-date, high-quality evidence and guidelines to standardize care and curtail "dependency" between patient and providers; and co-location of providers to strengthen existing interprofessional communication and relationships. Key informants called for patient care that is collaborative, integrated and patient-centered, rather than "patient-driven" care; civilian providers understanding and respecting military culture rather than assuming transferability of patient management processes from the public civilian sector; standardization of communication protocols and measures to evaluate outcomes of care; and the need to move slowly and respectfully within the current CAF health care system if planning the on-base implementation of chiropractic services. CONCLUSION This study illuminated many opportunities and barriers, in complex and diverse domains, related to introducing collaborative chiropractic services in the CFHS. The findings are relevant to increasing understanding and strengthening interprofessional collaborative care within the unique CAF health care delivery system.
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Affiliation(s)
- Silvano A Mior
- Department of Research and Innovation, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, Canada
| | - Ellen Vogel
- University of Ontario Institute of Technology, Faculty of Health Sciences, 2000 Simcoe Street North, Oshawa, Ontario, Canada
| | - Deborah Sutton
- Queen's University, Rehabilitation Science, Faculty of Health Sciences, Louise D Acton Building, Kingston, Ontario, Canada
| | - Simon French
- Queen's University, Rehabilitation Science, Faculty of Health Sciences, Louise D Acton Building, Kingston, Ontario, Canada.,Department of Chiropractic, Macquarie University, NSW, Australia
| | - Pierre Côté
- Department of Research and Innovation, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, Canada.,University of Ontario Institute of Technology, Faculty of Health Sciences, 2000 Simcoe Street North, Oshawa, Ontario, Canada
| | | | - Patrick Loisel
- University of Toronto, Institute of Health Policy, Management and Evaluation, 155 College Street, 4th Floor, Toronto, Ontario, Canada
| | - Audrey Laporte
- University of Toronto, Institute of Health Policy, Management and Evaluation, 155 College Street, 4th Floor, Toronto, Ontario, Canada.,Canadian Centre for Health Economics, 155 College Street, 4th Floor, Toronto, Ontario, Canada
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27
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Purcell N, Zamora K, Gibson C, Tighe J, Chang J, Grasso J, Seal KH. Patient Experiences With Integrated Pain Care: A Qualitative Evaluation of One VA's Biopsychosocial Approach to Chronic Pain Treatment and Opioid Safety. Glob Adv Health Med 2019; 8:2164956119838845. [PMID: 31041143 PMCID: PMC6480990 DOI: 10.1177/2164956119838845] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/27/2019] [Indexed: 01/08/2023] Open
Abstract
Background Mounting concern about the risks and limited effectiveness of opioid therapy for chronic pain has spurred the implementation of novel integrated biopsychosocial pain care models in health-care systems like the Department of Veterans Affairs (VA). However, little is known about patient experiences with these new care models. Objective We conducted a qualitative study to examine patient experiences with a pain care model currently being disseminated at the VA: interdisciplinary, integrated pain teams (IPTs) embedded in primary care. Method We interviewed 41 veterans who received care from VA’s first IPT to learn how working with the team impacted their pain care and quality of life. We asked about their overall experience with IPT, what worked and did not work for them, and what changes they would recommend to improve IPT care. Results The interviews revealed a wide spectrum of patient experiences and varying perspectives on the extent to which the new model improved their pain and quality of life. Thematic analysis shed light on factors impacting patients’ experiences, including pretreatment goals and expectations as well as attitudes toward opioids and nonpharmacological treatments. Conclusion We discuss the implications of our findings for national efforts to implement biopsychosocial pain care, and we offer recommendations to promote patient-centered implementation.
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Affiliation(s)
- Natalie Purcell
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Kara Zamora
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Carolyn Gibson
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Jennifer Tighe
- San Francisco VA Health Care System, San Francisco, California
| | - Jamie Chang
- San Francisco VA Health Care System, San Francisco, California.,Santa Clara University, Santa Clara, California
| | - Joseph Grasso
- San Francisco VA Health Care System, San Francisco, California
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
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28
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Becker WC, Mattocks KM, Frank JW, Bair MJ, Jankowski RL, Kerns RD, Painter JT, Fenton BT, Midboe AM, Martino S. Mixed methods formative evaluation of a collaborative care program to decrease risky opioid prescribing and increase non-pharmacologic approaches to pain management. Addict Behav 2018; 86:138-145. [PMID: 29576479 DOI: 10.1016/j.addbeh.2018.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/30/2018] [Accepted: 03/06/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Opioid prescribing and subsequent rates of serious harms have dramatically increased in the past two decades, yet there are still significant barriers to reduction of risky opioid regimens. This formative evaluation utilized a mixed-methods approach to identify barriers and factors that may facilitate the successful implementation of Primary Care-Integrated Pain Support (PIPS), a clinical program designed to support the reduction of risky opioid regimens while increasing the uptake of non-pharmacologic treatment modalities. METHODS Eighteen Department of Veterans Affairs (VA) employees across three sites completed a survey consisting of the Organizational Readiness for Implementing Change (ORIC) scale; a subset of these individuals (n = 9) then completed a semi-structured qualitative phone interview regarding implementing PIPS within the VA. ORIC results were analyzed using descriptive statistics while interview transcripts were coded and sorted according to qualitative themes. RESULTS Quantitative analysis based on ORIC indicated high levels of organizational readiness to implement PIPS. Interview analysis revealed several salient themes: system-level barriers such as tension among various pain management providers; patient-level barriers such as perception of support and tension between patient and provider; and facilitating factors of PIPS, such as the importance of the clinical pharmacist role. CONCLUSIONS While organizational readiness for implementing PIPS appears high, modifications to our implementation facilitation strategy (e.g., establishing clinical pharmacists as champions; marketing PIPS to leadership as a way to improve VA opioid safety metrics) may improve capacity of the sites to implement PIPS successfully.
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29
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Chui PW, Bastian LA, DeRycke E, Brandt CA, Becker WC, Goulet JL. Dual Use of Department of Veterans Affairs and Medicare Benefits on High-Risk Opioid Prescriptions in Veterans Aged 65 Years and Older: Insights from the VA Musculoskeletal Disorders Cohort. Health Serv Res 2018; 53 Suppl 3:5402-5418. [PMID: 30298672 DOI: 10.1111/1475-6773.13060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To examine the association of dual use of both Veterans Health Administration (VHA) and Medicare benefits with high-risk opioid prescriptions among Veterans aged 65 years and older with a musculoskeletal disorder diagnosis. DATA SOURCES/STUDY SETTING Data were obtained from the VA Musculoskeletal Disorder (MSD) cohort and national Medicare claims data from 2008 to 2010. STUDY DESIGN We conducted a retrospective analysis of Veterans enrolled in Medicare to examine the association of dual use with long-term opioid use (>90 days of prescription opioids/year) and overlapping opioid prescriptions. Multivariable logistic regression was performed adjusting for demographic and clinical characteristics. DATA COLLECTION/EXTRACTION METHODS We identified 21,111 Veterans enrolled in Medicare who entered the MSD cohort in 2008 and received an opioid prescription in 2010. We linked VHA data with Medicare claims data to identify opioid prescriptions for these Veterans in 2010. PRINCIPAL FINDINGS As compared to Veterans who used only VHA or Medicare, Veterans with dual use of VHA and Medicare were significantly more likely to be prescribed long-term opioid therapy (OR = 4.61 (95 percent CI 4.05-5.25) and were also found to have higher median number of opioid prescriptions and higher odds of overlapping opioid prescriptions in 1 year. Patients reporting moderate-to-severe pain, non-white-race/ethnicity, and higher scoring on the Charlson comorbidity index had significantly higher odds of long-term opioid prescriptions. CONCLUSIONS Among Veterans aged 65 years or older, dual use of both VHA and Medicare was associated with higher odds of long-term opioid therapy. Our findings suggest there may be benefit to combining VHA and non-VHA electronic health record data to minimize exposure to high-risk opioid prescribing.
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Affiliation(s)
- Philip W Chui
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Lori A Bastian
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Eric DeRycke
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
| | - Cynthia A Brandt
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - William C Becker
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Joseph L Goulet
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
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Speed TJ, Parekh V, Coe W, Antoine D. Comorbid chronic pain and opioid use disorder: literature review and potential treatment innovations. Int Rev Psychiatry 2018; 30:136-146. [PMID: 30398071 DOI: 10.1080/09540261.2018.1514369] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Chronic pain (CP) and opioid use disorder (OUD) remain challenging complex public health concerns. This is an updated review on the relationship between CP and OUD and the use of stepped care models for assessment and management of this vulnerable population. A literature search was conducted from 2008 to the present in PubMed, Embase, and PsycInfo using the terms pain or chronic pain and opioid-related disorders, opiate, methadone, buprenorphine, naltrexone, opioid abuse, opioid misuse, opioid dependen*, heroin addict, heroin abuse, heroin misuse, heroin dependen*, or analgesic opioids, and stepped care, integrated services, multidisciplinary treatment, or reinforcement-based treatment. Evidenced-based data exists on the feasibility, implementation, and efficacy of stepped care models in primary care settings for the management of CP and opioid use. Although these studies did not enroll participants with OUD, they included a sub-set of patients at risk for the development of OUD. There remains a dearth of treatment options for those with comorbid CP and OUD. Future research is needed to explore the aetiology and impact of CP and OUD, and greater emphasis is needed to improve access to comprehensive pain and substance use programmes for high-risk individuals.
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Affiliation(s)
- Traci J Speed
- a Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Vinay Parekh
- a Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - William Coe
- a Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Denis Antoine
- a Psychiatry and Behavioral Sciences , Johns Hopkins University School of Medicine , Baltimore , MD , USA
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Kligler B, Bair MJ, Banerjea R, DeBar L, Ezeji-Okoye S, Lisi A, Murphy JL, Sandbrink F, Cherkin DC. Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain. J Gen Intern Med 2018; 33:16-23. [PMID: 29633133 PMCID: PMC5902342 DOI: 10.1007/s11606-018-4323-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.
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Affiliation(s)
- Benjamin Kligler
- Veterans Health Administration, Washington, DC, USA. .,Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Matthew J Bair
- Veterans Health Administration, Washington, DC, USA.,Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Lynn DeBar
- Kaiser Permanente Center for Health Research, Portland, OR, USA.,Oregon Health Sciences University, Portland, OR, USA
| | | | - Anthony Lisi
- Veterans Health Administration, Washington, DC, USA.,Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Daniel C Cherkin
- Kaiser Permanente, Washington Health Research Institute, Seattle, WA, USA
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Peterson K, Anderson J, Bourne D, Mackey K, Helfand M. Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain: a Rapid Evidence Review. J Gen Intern Med 2018; 33:71-81. [PMID: 29633140 PMCID: PMC5902347 DOI: 10.1007/s11606-018-4328-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Primary care providers (PCPs) face many system- and patient-level challenges in providing multimodal care for patients with complex chronic pain as recommended in some pain management guidelines. Several models have been developed to improve the delivery of multimodal chronic pain care. These models vary in their key components, and work is needed to identify which have the strongest evidence of clinically-important improvements in pain and function. Our objective was to determine which primary care-based multimodal chronic pain care models provide clinically relevant benefits, define key elements of these models, and identify patients who are most likely to benefit. METHODS To identify studies, we searched MEDLINE® (1996 to October 2016), CINAHL, reference lists, and numerous other sources and consulted with experts. We used predefined criteria for study selection, data abstraction, internal validity assessment, and strength of evidence grading. RESULTS We identified nine models, evaluated in mostly randomized controlled trials (RCTs). The RCTs included 3816 individuals primarily from the USA. The most common pain location was the back. Five models primarily coupling a decision-support component-most commonly algorithm-guided treatment and/or stepped care-with proactive ongoing treatment monitoring have the best evidence of providing clinically relevant improvement in pain intensity and pain-related function over 9 to 12 months (NNT range, 4 to 13) and variable improvement in quality of life, depression, anxiety, and sleep. The strength of the evidence was generally low, as each model was only supported by a single RCT with imprecise findings. DISCUSSION Multimodal chronic pain care delivery models coupling decision support with proactive treatment monitoring consistently provide clinically relevant improvement in pain and function. Wider implementation of these models should be accompanied by further evaluation of clinical and implementation effectiveness.
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Affiliation(s)
- Kim Peterson
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA.
| | - Johanna Anderson
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
| | - Donald Bourne
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
| | - Katherine Mackey
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
| | - Mark Helfand
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
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Carey EP, Nolan C, Kerns RD, Ho PM, Frank JW. Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent Initiation of Long-Term Opioid Therapy. J Gen Intern Med 2018; 33:38-45. [PMID: 29633137 PMCID: PMC5902343 DOI: 10.1007/s11606-018-4324-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Expert guidelines recommend non-pharmacologic treatments and non-opioid medications for chronic pain and recommend against initiating long-term opioid therapy (LTOT). OBJECTIVE We examined whether veterans with incident chronic pain receiving care at facilities with greater utilization of non-pharmacologic treatments and non-opioid medications are less likely to initiate LTOT. DESIGN Retrospective cohort study PARTICIPANTS: Veterans receiving primary care from a Veterans Health Administration facility with incident chronic pain between 1/1/2010 and 12/31/2015 based on either of 2 criteria: (1) persistent moderate-to-severe patient-reported pain and (2) diagnoses "likely to represent" chronic pain. MAIN MEASURES The independent variable was facility-level utilization of pain-related treatment modalities (non-pharmacologic, non-opioid medications, LTOT) in the prior calendar year. The dependent variable was patient-level initiation of LTOT (≥ 90 days within 365 days) in the subsequent year, adjusting for patient characteristics. KEY RESULTS Among 1,094,569 veterans with incident chronic pain from 2010 to 2015, there was wide facility-level variation in utilization of 10 pain-related treatment modalities, including initiation of LTOT (median, 16%; range, 5-32%). Veterans receiving care at facilities with greater utilization of non-pharmacologic treatments were less likely to initiate LTOT in the year following incident chronic pain. Conversely, veterans receiving care at facilities with greater non-opioid and opioid medication utilization were more likely to initiate LTOT; this association was strongest for past year facility-level LTOT initiation (adjusted rate ratio, 2.10; 95% confidence interval, 2.06-2.15, top vs. bottom quartile of facility-level LTOT initiation in prior calendar year). CONCLUSIONS Facility-level utilization patterns of non-pharmacologic, non-opioid, and opioid treatments for chronic pain are associated with subsequent patient-level initiation of LTOT among veterans with incident chronic pain. Further studies should seek to understand facility-level variation in chronic pain care and to identify facility-level utilization patterns that are associated with improved patient outcomes.
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Affiliation(s)
- Evan P Carey
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Charlotte Nolan
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA.,Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, USA
| | - P Michael Ho
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA.,Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph W Frank
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA. .,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
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Purcell N, Zamora K, Tighe J, Li Y, Douraghi M, Seal K. The Integrated Pain Team: A Mixed-Methods Evaluation of the Impact of an Embedded Interdisciplinary Pain Care Intervention on Primary Care Team Satisfaction, Confidence, and Perceptions of Care Effectiveness. PAIN MEDICINE 2017; 19:1748-1763. [DOI: 10.1093/pm/pnx254] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Natalie Purcell
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- University of California, San Francisco, San Francisco, California, USA
| | - Kara Zamora
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Jenny Tighe
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Mathew Douraghi
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Karen Seal
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- University of California, San Francisco, San Francisco, California, USA
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Ducoffe AR, York A, Hu DJ, Perfetto D, Kerns RD. National Action Plan for Adverse Drug Event Prevention: Recommendations for Safer Outpatient Opioid Use. PAIN MEDICINE (MALDEN, MASS.) 2016; 17:2291-2304. [PMID: 28025363 PMCID: PMC6280931 DOI: 10.1093/pm/pnw106] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Adverse drug events (ADEs) have been highlighted as a major patient safety and public health challenge by the National Action Plan for Adverse Drug Event Prevention (ADE Action Plan), which was released by the Office of Disease Prevention and Health Promotion (ODPHP) in August 2014. The ADE Action Plan focuses on surveillance, evidence-based prevention, incentives, and oversights, additional research needs as well as possible measures and metrics to track progress of ADE prevention within three drug classes: anticoagulants, diabetes agents, and opioids.Objectives and Recommendations. With outpatient opioid prescriptions being a great concern among many healthcare providers, this article focuses on recommendations from the ADE Action Plan to help guide safer opioid use in healthcare delivery settings. Its aim is to discuss current federal methods in place to prevent opioid ADEs while also providing evidence to encourage providers and hospitals to innovate new systems and practices to increase prevention.
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Affiliation(s)
- Aaron R Ducoffe
- *Previously with Office of Disease Prevention and Health Promotion (ODPHP), US Department of Health and Human Services, Washington, DC; Currently with MedStar Georgetown University Hospital, Department of Radiology, Washington, DC
| | - Andrew York
- Previously with ODPHP, Washington, DC; Currently with Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Dale J Hu
- Previously with ODPHP, Washington, DC; Currently with National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | | | - Robert D Kerns
- Previously with the Pain Research, Informatics, Multi-Morbidities and Education (PRIME) Center, Virginia Connecticut Healthcare System, West Haven, Connecticut; Currently with Yale University, New Haven, Connecticut, USA
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Anderson DR, Zlateva I, Coman EN, Khatri K, Tian T, Kerns RD. Improving pain care through implementation of the Stepped Care Model at a multisite community health center. J Pain Res 2016; 9:1021-1029. [PMID: 27881926 PMCID: PMC5115680 DOI: 10.2147/jpr.s117885] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Treating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center. METHODS The Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 preintervention and 4,385 postintervention) cared for at Community Health Center, Inc. Data were collected from the electronic health record and supplemented by chart reviews. Surveys were administered to PCPs to assess knowledge, attitudes, and confidence. RESULTS Providers' pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing. CONCLUSION Implementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes.
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Affiliation(s)
| | - Ianita Zlateva
- Weitzman Institute, Community Health Center, Inc., Middletown
| | - Emil N Coman
- UCONN Health Disparities Institute, University of Connecticut, Farmington
| | - Khushbu Khatri
- Weitzman Institute, Community Health Center, Inc., Middletown
| | - Terrence Tian
- Weitzman Institute, Community Health Center, Inc., Middletown
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Alawadi ZM, Leal IM, Flores JR, Holihan JL, Henchcliffe BE, Mitchell TO, Ko TC, Liang MK, Kao LS. Underserved Patients Seeking Care for Ventral Hernias at a Safety Net Hospital: Impact on Quality of Life and Expectations of Treatment. J Am Coll Surg 2016; 224:26-34.e2. [PMID: 27742485 DOI: 10.1016/j.jamcollsurg.2016.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/19/2016] [Accepted: 09/21/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to identify issues important to patients in their decision-making, expectations, and satisfaction when seeking treatment for a ventral hernia. STUDY DESIGN An exploratory qualitative study was conducted of adult patients with ventral hernias seeking care at a safety-net hospital. Two semi-structured interviews were conducted with each patient: before and 6 months after surgical consultation. Interviews were audiotaped, transcribed, and coded using latent content analysis until data saturation was achieved. RESULTS Of patients completing an initial interview (n = 30), 27 (90%) completed follow-up interviews. Half of the patients were Spanish-speaking, one-third had a previous ventral hernia repair, and two-thirds underwent initial nonoperative management after surgical consultation. Patient-described factors guiding management decisions included impact on quality of life, primarily pain and limited function; overwhelming challenges to meeting surgical criteria, primarily obesity; and assuming responsibility to avoid recurrence. Patients were uninformed regarding potential poor outcomes and contributing factors, even among patients with a previous ventral hernia repair, with most attributing recurrence to inadequate self-management. CONCLUSIONS Understanding patients' perspective is crucial to engaging them as stakeholders in their care, addressing their concerns, and improving clinical and patient-centered outcomes. Patient reports suggest how care can be improved through developing more effective strategies for addressing patients' concerns during nonoperative management, preoperative risk reduction strategies that are sensitive to their sociodemographic characteristics, treatment plans that harness patients' willingness for self-management, and patient education and decision-making tools.
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Affiliation(s)
- Zeinab M Alawadi
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX.
| | - Isabel M Leal
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
| | - Juan R Flores
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
| | - Julie L Holihan
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
| | - Blake E Henchcliffe
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
| | - Thomas O Mitchell
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
| | - Tien C Ko
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
| | - Mike K Liang
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
| | - Lillian S Kao
- Department of Surgery, University of Texas Health Sciences Center, Houston, TX
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Becker WC. Rigorous Epidemiologic Work Shows Positive Impact of VHA’s Efforts to Rein in Opioid Prescribing. PAIN MEDICINE 2016; 17:1209-1210. [DOI: 10.1093/pm/pnw053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, Williams JL, McFarland BH. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain. THE JOURNAL OF PAIN 2016; 17:824-35. [PMID: 27058162 DOI: 10.1016/j.jpain.2016.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
UNLABELLED Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes. PERSPECTIVE This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Dawn M Peters
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - J Lucas Williams
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
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Green BN, Johnson CD, Daniels CJ, Napuli JG, Gliedt JA, Paris DJ. Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature. J Evid Based Complementary Altern Med 2016; 21:115-30. [PMID: 26677851 DOI: 10.1177/2156587215621461] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023] Open
Abstract
This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. A systematic search of Medline, CINAHL, and Index to Chiropractic Literature was performed from inception through April 2015. Thirty articles met inclusion criteria. Studies reporting utilization and policy show that chiropractic services are successfully implemented in various military and veteran health care settings and that integration varies by facility. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.
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Affiliation(s)
- Bart N Green
- Naval Medical Center San Diego, San Diego, CA, USA National University of Health Sciences, Lombard, IL, USA
| | | | | | - Jason G Napuli
- National University of Health Sciences, Lombard, IL, USA Bay Pines VA Healthcare System, Bay Pines, FL, USA New York Chiropractic College, Seneca Falls, NY, USA
| | | | - David J Paris
- VA Northern California Health Care System, Redding, CA, USA Palmer College of Chiropractic, Davenport, IA, USA
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Moore BA, Anderson D, Dorflinger L, Zlateva I, Lee A, Gilliam W, Tian T, Khatri K, Ruser CB, Kerns RD. Stepped care model of pain management and quality of pain care in long-term opioid therapy. ACTA ACUST UNITED AC 2016; 53:137-46. [PMID: 27006068 DOI: 10.1682/jrrd.2014.10.0254] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 09/11/2015] [Indexed: 11/05/2022]
Abstract
Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.
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Affiliation(s)
- Brent A Moore
- Pain Research, Informatics, Multimorbidities and Education Center, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, and Yale School of Medicine, New Haven, CT
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Burgess DJ, Gravely AA, Nelson DB, Bair MJ, Kerns RD, Higgins DM, Farmer MM, Partin MR. Association between pain outcomes and race and opioid treatment: Retrospective cohort study of Veterans. ACTA ACUST UNITED AC 2016; 53:13-24. [DOI: 10.1682/jrrd.2014.10.0252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 09/11/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Diana J. Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
| | - Amy A. Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
| | - David B. Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
| | - Matthew J. Bair
- Center for Health Information and Communication, VA Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, IN; and Regenstrief Institute Inc, Indianapolis, IN
| | - Robert D. Kerns
- VA Connecticut Healthcare System, West Haven, CT; and Yale School of Medicine, New Haven, CT
| | - Diana M. Higgins
- VA Connecticut Healthcare System, West Haven, CT; and Yale School of Medicine, New Haven, CT
| | - Melissa M. Farmer
- VA Health Services Research and Development Service, Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA
| | - Melissa R. Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
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Behavioral treatments for migraine management: useful at each step of migraine care. Curr Neurol Neurosci Rep 2015; 15:14. [PMID: 25708673 DOI: 10.1007/s11910-015-0533-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Migraine is a disabling and prevalent disorder. Migraine is most effectively treated with a stepped care approach, where patients initially receive a broad level of care (primary care) and proceed to receive increasingly specialized care throughout the course of treatment. Behavioral treatments for migraine modify behaviors of people with migraine with the intention to prevent migraine episodes and secondary consequence of migraine. Behavioral treatments can be incorporated into each level of the stepped care approach for migraine treatment. In this article, we provide a rationale for including behavioral treatment strategies in the treatment of migraine. We then describe and review the evidence for behavioral treatment strategies for migraine, including patient education, relaxation strategies, biofeedback, and cognitive behavioral treatment strategies. Finally, we describe how behavioral treatments can be integrated into a stepped care approach for migraine care.
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Frank JW, Carey EP, Fagan KM, Aron DC, Todd-Stenberg J, Moore BA, Kerns RD, Au DH, Ho PM, Kirsh SR. Evaluation of a Telementoring Intervention for Pain Management in the Veterans Health Administration. PAIN MEDICINE 2015; 16:1090-100. [DOI: 10.1111/pme.12715] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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