1
|
Daniels SI, Cave S, Wagner TH, Perez TA, Edmond SN, Becker WC, Midboe AM. Implementation, intervention, and downstream costs for implementation of a multidisciplinary complex pain clinic in the Veterans Health Administration. Health Serv Res 2024. [PMID: 38956400 DOI: 10.1111/1475-6773.14345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE To determine the budget impact of implementing multidisciplinary complex pain clinics (MCPCs) for Veterans Health Administration (VA) patients living with complex chronic pain and substance use disorder comorbidities who are on risky opioid regimens. DATA SOURCES AND STUDY SETTING We measured implementation costs for three MCPCs over 2 years using micro-costing methods. Intervention and downstream costs were obtained from the VA Managerial Cost Accounting System from 2 years prior to 2 years after opening of MCPCs. STUDY DESIGN Staff at the three VA sites implementing MCPCs were supported by Implementation Facilitation. The intervention cohort was patients at MCPC sites who received treatment based on their history of chronic pain and risky opioid use. Intervention costs and downstream costs were estimated with a quasi-experimental study design using a propensity score-weighted difference-in-difference approach. The healthcare utilization costs of treated patients were compared with a control group having clinically similar characteristics and undergoing the standard route of care at neighboring VA medical centers. Cancer and hospice patients were excluded. DATA COLLECTION/EXTRACTION METHODS Activity-based costing data acquired from MCPC sites were used to estimate implementation costs. Intervention and downstream costs were extracted from VA administrative data. PRINCIPAL FINDINGS Average Implementation Facilitation costs ranged from $380 to $640 per month for each site. Upon opening of three MCPCs, average intervention costs per patient were significantly higher than the control group at two intervention sites. Downstream costs were significantly higher at only one of three intervention sites. Site-level differences were due to variation in inpatient costs, with some confounding likely due to the COVID-19 pandemic. This evidence suggests that necessary start-up investments are required to initiate MCPCs, with allocations of funds needed for implementation, intervention, and downstream costs. CONCLUSIONS Incorporating implementation, intervention, and downstream costs in this evaluation provides a thorough budget impact analysis, which decision-makers may use when considering whether to expand effective programming.
Collapse
Affiliation(s)
- Sarah I Daniels
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Shayna Cave
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Todd H Wagner
- Health Economics and Research Center, Center for Policy Evaluation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Taryn A Perez
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center for Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center for Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Public Health Sciences, Division of Health Policy and Management, University of California Davis-School of Medicine, Davis, California, USA
| |
Collapse
|
2
|
Hebard S, Weaver G, Hansen WB, Ruppert S. Evaluation of a Pilot Program to Prevent the Misuse of Prescribed Opioids Among Health Care Workers: Repeated Measures Survey Study. JMIR Form Res 2024; 8:e53665. [PMID: 38607664 PMCID: PMC11053396 DOI: 10.2196/53665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Overprescription of opioids has led to increased misuse of opioids, resulting in higher rates of overdose. The workplace can play a vital role in an individual's intentions to misuse prescription opioids with injured workers being prescribed opioids, at a rate 3 times the national average. For example, health care workers are at risk for injuries, opioid dispensing, and diversion. Intervening within a context that may contribute to risks for opioid misuse while targeting individual psychosocial factors may be a useful complement to interventions at policy and prescribing levels. OBJECTIVE This pilot study assessed the effects of a mobile-friendly opioid misuse intervention prototype tailored for health care workers using the preparation phase of a multiphase optimization strategy design. METHODS A total of 33 health care practitioners participated in the pilot intervention, which included 10 brief web-based lessons aimed at impacting psychosocial measures that underlie opioid misuse. The lesson topics included: addiction beliefs, addiction control, Centers for Disease Control and Prevention guidelines and recommendations, beliefs about patient-provider relationships and communication, control in communicating with providers, beliefs about self-monitoring pain and side effects, control in self-monitoring pain and side effects, diversion and disposal beliefs, diversion and disposal control, and a conclusion lesson. Using a treatment-only design, pretest and posttest surveys were collected. A general linear repeated measures ANOVA was used to assess mean differences from pretest to posttest. Descriptive statistics were used to assess participant feedback about the intervention. RESULTS After completing the intervention, participants showed significant mean changes with increases in knowledge of opioids (+0.459; P<.001), less favorable attitudes toward opioids (-1.081; P=.001), more positive beliefs about communication with providers (+0.205; P=.01), more positive beliefs about pain management control (+0.969; P<.001), and increased intentions to avoid opioid use (+0.212; P=.03). Of the 33 practitioners who completed the program, most felt positive about the information presented, and almost 70% (23/33) agreed or strongly agreed that other workers in the industry should complete a program like this. CONCLUSIONS While attempts to address the opioid crisis have been made through public health policies and prescribing initiatives, opioid misuse continues to rise. Certain industries place workers at greater risk for injury and opioid dispensing, making interventions that target workers in these industries of particular importance. Results from this pilot study show positive impacts on knowledge, attitudes, and beliefs about communicating with providers and pain management control, as well as intentions to avoid opioid misuse. However, the dropout rate and small sample size are severe limitations, and the results lack generalizability. Results will be used to inform program revisions and future optimization trials, with the intention of providing insight for future intervention development and evaluation of mobile-friendly eHealth interventions for employees.
Collapse
Affiliation(s)
| | - GracieLee Weaver
- Department of Public Health Education, University of North Carolina Greensboro, Greensboro, NC, United States
| | | | - Scarlett Ruppert
- Department of Public Health Education, University of North Carolina Greensboro, Greensboro, NC, United States
| |
Collapse
|
3
|
Wesolowicz DM, Spelman JF, Edmond SN, Schwartz AR, Kravetz JD, Edens EL, Becker WC. Increasing buprenorphine access for patients with chronic pain: a quality improvement initiative. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:226-230. [PMID: 37847654 DOI: 10.1093/pm/pnad140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Buprenorphine is effective for chronic pain and safer than full-agonist opioids; however, limited education about and support for buprenorphine can result in under-prescribing in primary care and reduced access in specialty pain clinics. The purpose of this quality improvement initiative was to optimize and evaluate procedures for transferring patients stable on buprenorphine for chronic pain from a specialty pain clinic back to primary care. SETTING Eight primary care clinics within a Veterans Health Administration health care system. METHODS A standard operating procedure for facilitated transfer of prescribing was developed after a needs assessment and was introduced during an educational session with primary care providers, and providers completed a survey assessing attitudes about buprenorphine prescribing. Success of the initiative was measured through the number of patients transferred back to primary care over the course of 18 months. RESULTS Survey results indicated that primary care providers with previous experience prescribing buprenorphine were more likely to view buprenorphine prescribing for pain as within the scope of their practice and to endorse feeling comfortable managing a buprenorphine regimen. Providers identified systemic and educational barriers to prescribing, and they identified ongoing support from specialty pain care and primary care as a facilitator of prescribing. Metrics suggested that the standard operating procedure was generally successful in transferring and retaining eligible patients in primary care. CONCLUSION This quality improvement initiative suggests that a facilitated transfer procedure can be useful in increasing buprenorphine prescribing for pain in primary care. Future efforts to increase primary care provider comfort and address systemic barriers to buprenorphine prescribing are needed.
Collapse
Affiliation(s)
- Danielle M Wesolowicz
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06504, United States
| | - Juliette F Spelman
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| | - Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06504, United States
| | - Amy R Schwartz
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| | - Jeffrey D Kravetz
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| | - Ellen L Edens
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06504, United States
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| |
Collapse
|
4
|
Rogers DG, Frank JW, Wesolowicz DM, Nolan C, Schroeder A, Falker C, Abelleira A, Moore BA, Becker WC, Edmond SN. Video-telecare collaborative pain management during COVID-19: a single-arm feasibility study. BMC PRIMARY CARE 2023; 24:134. [PMID: 37386370 PMCID: PMC10308713 DOI: 10.1186/s12875-023-02052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/02/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic. METHODS The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management. RESULTS Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (ΔMEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions. CONCLUSION Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed.
Collapse
Affiliation(s)
- Daniel G. Rogers
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | - Joseph W. Frank
- VA Eastern Colorado Health Care System, Aurora, USA
- University of Colorado School of Medicine, Aurora, USA
| | - Danielle M. Wesolowicz
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | | | | | - Caroline Falker
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Audrey Abelleira
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | - Brent A. Moore
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | - William C. Becker
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Sara N. Edmond
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| |
Collapse
|
5
|
Salloum RG, Wagner TH, Midboe AM, Daniels SI, Quanbeck A, Chambers DA. The economics of adaptations to evidence-based practices. Implement Sci Commun 2022; 3:100. [PMID: 36153575 PMCID: PMC9509646 DOI: 10.1186/s43058-022-00345-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background Evidence-based practices (EBPs) are frequently adapted in response to the dynamic contexts in which they are implemented. Adaptation is defined as the degree to which an EBP is altered to fit the setting or to improve fit to local context and can be planned or unplanned. Although adaptations are common and necessary to maximizing the marginal impact of EBPs, little attention has been given to the economic consequences and how adaptations affect marginal costs. Discussion In assessing the economic consequences of adaptation, one should consider its impact on core components, the planned adaptive periphery, and the unplanned adaptive periphery. Guided by implementation science frameworks, we examine how various economic evaluation approaches accommodate the influence of adaptations and discuss the pros and cons of these approaches. Using the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME), mixed methods can elucidate the economic reasons driving the adaptations. Micro-costing approaches are applied in research that integrates the adaptation of EBPs at the planning stage using innovative, adaptive study designs. In contrast, evaluation of unplanned adaptation is subject to confounding and requires sensitivity analysis to address unobservable measures and other uncertainties. A case study is presented using the RE-AIM framework to illustrate the costing of adaptations. In addition to empirical approaches to evaluating adaptation, simulation modeling approaches can be used to overcome limited follow-up in implementation studies. Conclusions As implementation science evolves to improve our understanding of the mechanisms and implications of adaptations, it is increasingly important to understand the economic implications of such adaptations, in addition to their impact on clinical effectiveness. Therefore, explicit consideration is warranted of how costs can be evaluated as outcomes of adaptations to the delivery of EBPs.
Collapse
|
6
|
Ibrahim SA, Reynolds KA, Poon E, Alam M. The evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ 2022; 377:e063064. [PMID: 35738660 PMCID: PMC9215261 DOI: 10.1136/bmj-2020-063064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. DESIGN Cross sectional study. SETTING United States. PARTICIPANTS Four Joint Commission R3 (requirement, rationale, and reference) reports released by July 2018 and intended to become effective between 1 July 2018 and 1 July 2019. INTERVENTIONS From each R3 report the associated standard and its specific elements of performance (or actionable standards) were extracted. If an actionable standard enumerated multiple requirements, these were separated into distinct components. Two investigators reviewed full text references, and each actionable standard was classified as either completely supported, partly supported, or not supported; Oxford evidence quality ratings were assigned; and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the strength of recommendations. MAIN OUTCOME MEASURE Strengths of recommendation for actionable standards. RESULTS 20 actionable standards with 76 distinct components were accompanied by 48 references. Of the 20 actionable standards, six (30%) were completely supported by cited references, six were partly supported (30%), and eight (40%) were not supported. Of the six directly supported actionable standards, one (17%) cited at least one reference of level 1 or 2 evidence, none cited at least one reference of level 3 evidence, and five (83%) cited references of level 4 or 5 evidence. Of the completely supported actionable standards, strength of recommendation in five was deemed GRADE D and in one was GRADE B. CONCLUSIONS In general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.
Collapse
Affiliation(s)
- Sarah A Ibrahim
- Rush Medical College, Chicago, IL, USA
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kelly A Reynolds
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Emily Poon
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Murad Alam
- Department of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
7
|
Opioids for chronic pain management in patients with dialysis-dependent kidney failure. Nat Rev Nephrol 2022; 18:113-128. [PMID: 34621058 PMCID: PMC8792317 DOI: 10.1038/s41581-021-00484-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/30/2022]
Abstract
Chronic pain is highly prevalent among adults treated with maintenance haemodialysis (HD) and has profound negative effects. Over four decades, research has demonstrated that 50-80% of adult patients treated with HD report having pain. Half of patients with HD-dependent kidney failure (HDKF) have chronic moderate-to-severe pain, which is similar to the burden of pain in patients with cancer. However, pain management in patients with HDKF is often ineffective as most patients report that their pain is inadequately treated. Opioid analgesics are prescribed more frequently for patients receiving HD than for individuals in the general population with chronic pain, and are associated with increased morbidity, mortality and health-care resource use. Furthermore, current opioid prescribing patterns are frequently inconsistent with guideline-recommended care. Evidence for the effectiveness of opioids in pain management in general, and in patients with HDKF specifically, is lacking. Nonetheless, long-term opioid therapy has a role in the treatment of some patients when used selectively, carefully and combined with an ongoing assessment of risks and benefits. Here, we provide a comprehensive overview of the use of opioid therapy in patients with HDKF and chronic pain, including a discussion of buprenorphine, which has potential as an analgesic option for patients receiving HD owing to its unique pharmacological properties.
Collapse
|
8
|
Edmond SN, Currie S, Gehrke A, Falker CG, Sung M, Abelleira A, Edens EL, Becker WC. Optimizing interdisciplinary virtual pain care and buprenorphine initiation during COVID-19: a quality improvement study. PAIN MEDICINE 2021; 23:1043-1046. [PMID: 34940877 PMCID: PMC9383145 DOI: 10.1093/pm/pnab348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Sara N Edmond
- VA Connecticut Healthcare System, West Haven, CT.,Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | | | - Amanda Gehrke
- Bay Pines VA Healthcare System-Lee County VA Health Care Center, Cape Coral, FL
| | - Caroline G Falker
- VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Minhee Sung
- VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | | | - Ellen L Edens
- VA Connecticut Healthcare System, West Haven, CT.,Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - William C Becker
- VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
9
|
Sowicz TJ, Hausmann LRM. Veterans' Experiences of an Opioid Specialty Clinic. PAIN MEDICINE 2021; 22:2242-2251. [PMID: 33693898 DOI: 10.1093/pm/pnab096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Opioid specialty clinics have emerged as an approach for mitigating the risks associated with opioid therapies. Many opioid specialty clinics within the Department of Veterans Affairs (VA) have been described in the extant literature, yet veterans' experiences of these remain absent. This research study was undertaken to describe veterans' responses (e.g., knowledge, attitudes, and beliefs) toward being evaluated in an opioid specialty clinic. DESIGN Qualitative descriptive research study. SETTING A VA medical center in the northeast United States. SUBJECTS Twenty veterans were interviewed between December 2017 and May 2018. METHODS Veterans' characteristics were extracted from the VA's electronic health record and analyzed with descriptive statistics. Qualitative data about veterans' experiences with the opioid specialty clinic were collected via semistructured interviews (in person or via telephone) and were analyzed with qualitative content analysis. RESULTS Most participants were older, non-Hispanic or non-Latino white men. Generally, veterans had positive experiences in the opioid specialty clinic. However, there was wide variation in their understanding of the purpose of the clinic, who staffed the clinic, and why they had been referred to the clinic. CONCLUSIONS For veterans prescribed opioid therapies, this clinic served as an adjunct service for ensuring appropriate and safe prescribing. Data from this study can be used to inform interventions to promote veterans' understanding across the total opioid safety clinic experience-referral, actual visit, and follow-up.
Collapse
Affiliation(s)
- Timothy Joseph Sowicz
- UNC Greensboro, Department of Family and Community Nursing, Greensboro, North Carolina, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Seal KH, Rife T, Li Y, Gibson C, Tighe J. Opioid Reduction and Risk Mitigation in VA Primary Care: Outcomes from the Integrated Pain Team Initiative. J Gen Intern Med 2020; 35:1238-1244. [PMID: 31848861 PMCID: PMC7174436 DOI: 10.1007/s11606-019-05572-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/04/2019] [Accepted: 11/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND National guidelines advise decreasing opioids for chronic pain, but there is no guidance on implementation. OBJECTIVE To evaluate the effectiveness of an Integrated Pain Team (IPT) clinic in decreasing opioid dose and mitigating opioid risk. DESIGN This study prospectively compared two matched cohorts receiving chronic pain care through IPT (N = 147) versus usual primary care (UPC, N = 147) over 6 months. Patients were matched on age, sex, psychiatric diagnoses, and baseline opioid dose. PATIENTS Veterans receiving care at a VA medical center or VA community-based clinics. INTERVENTION Interdisciplinary IPT, consisting of a collocated medical provider, psychologist, and pharmacist embedded in VA primary care providing short-term biopsychosocial management of veterans with chronic pain and problematic opioid use. MAIN MEASURES Change in opioid dose expressed as morphine equivalent daily dose (MEDD) and opioid risk mitigation evaluated at baseline, 3 months, and 6 months. KEY RESULTS Compared with veterans receiving UPC, those followed by IPT had a greater mean MEDD decrease of 42 mg versus 8 mg after 3 months and 56 mg versus 17 mg after 6 months. In adjusted analysis, compared with UPC, veterans in IPT achieved a 34-mg greater mean reduction at 3 months (p = 0.002) and 38-mg greater mean reduction at 6 months (p = 0.003). Nearly twice as many patients receiving care through IPT versus UPC reduced their daily opioid dose by ≥50%, representing more than a two-fold improvement at 3 months, which was sustained at 6 months [odds ratio = 2.03; 95% CI = 1.04-3.95, p = 0.04]. Significant improvements were also demonstrated in opioid risk mitigation by 6 months, including increased urine drug screen monitoring, naloxone kit distribution, and decreased co-prescription of opioids and benzodiazepines (all p values < 0.001). CONCLUSIONS Interdisciplinary biopsychosocial models of pain care can be embedded in primary care and lead to significant improvements in opioid dose and risk mitigation.
Collapse
Affiliation(s)
- Karen H Seal
- San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, CA, USA.
- Departments of Medicine and Psychiatry, University of California, San Francisco, San Francisco, CA, USA.
| | - Tessa Rife
- San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, CA, USA
- Departments of Medicine and Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn Gibson
- San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, CA, USA
- Departments of Medicine and Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Tighe
- San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
12
|
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Associations between initial opioid exposure and the likelihood for long-term use. J Am Pharm Assoc (2003) 2019; 59:17-22. [DOI: 10.1016/j.japh.2018.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/24/2018] [Accepted: 09/08/2018] [Indexed: 01/22/2023]
|
16
|
Slawek DE, Lu TY, Hayes B, Fox AD. Caring for Patients With Opioid Use Disorder: What Clinicians Should Know About Comorbid Medical Conditions. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2018. [PMCID: PMC9175890 DOI: 10.1176/appi.prcp.20180005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Opioid use disorder (OUD) is a growing problem, with opioid‐involved overdose deaths quadrupling since 1999 in the United States. This article reviews comorbid medical conditions related to OUD, starting with complications of behaviors associated with opioid use (e.g., injection drug use), followed by conditions stemming from the direct effects of opioids (e.g., hypogonadism). HIV and hepatitis C virus (HCV) are common infections in people with OUD, and treatment for these conditions can be safely provided regardless of ongoing substance use. Complications of drug injection, such as HIV, HCV, skin and soft tissue infections, and infective endocarditis, may be prevented through provision of sterile syringes and supervised injection facilities. Rare, life‐threatening bacterial infections may present with signs and symptoms that mimic intoxication, such as malaise or stupor, and should be assessed in patients with fever or positive blood cultures. In addition, chronic opioid exposure can lead to hypogonadism, opioid‐induced hyperalgesia, sleep‐disordered breathing, and potentially increased risk of cardiovascular disease and neurocognitive impairment. Pharmacotherapies for OUD (buprenorphine, methadone, and naltrexone) are safe and effective and their adverse opioid effects can be managed in clinical practice. Awareness of OUD‐associated medical conditions and their treatments is an important step in improving the health and wellness of people with OUD.
Collapse
Affiliation(s)
| | - Tiffany Y. Lu
- Department of MedicineAlbert Einstein College of MedicineBronxNY
| | - Benjamin Hayes
- Department of MedicineAlbert Einstein College of MedicineBronxNY
| | - Aaron D. Fox
- Department of MedicineAlbert Einstein College of MedicineBronxNY
| |
Collapse
|
17
|
Laycock H, Crawford V, Rice AS, Cox S. Lessons learnt from establishing a high dose opioid review clinic for people living with HIV. Pain Manag 2018; 9:37-44. [PMID: 30501569 DOI: 10.2217/pmt-2018-0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
People living with HIV represent a unique aging population, living with a chronic condition associated with significant pain. A number take high dose, long-term opioids to manage moderate to severe chronic pain, presenting specific risks. This article highlights the size and impact of this problem and outlines the service objectives and set up of a specialist clinic to manage people living with HIV on high dose opioids, alongside its successes and learning points.
Collapse
Affiliation(s)
- Helen Laycock
- Clinical Lecturer in Pain Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Vanessa Crawford
- Honorary Consultant Psychiatrist, HIV Pain Management Clinic, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Andrew Sc Rice
- Professor of Pain Research, Department of Surgery & Cancer, Imperial College London, London, UK.,Consultant in Pain Medicine, Department of Pain Medicine, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah Cox
- Consultant in Palliative Medicine, Department of Palliative Care, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
18
|
Peeters LM, van Munster CE, Van Wijmeersch B, Bruyndonckx R, Lamers I, Hellings N, Popescu V, Thalheim C, Feys P. Multidisciplinary data infrastructures in multiple sclerosis: Why they are needed and can be done! Mult Scler 2018; 25:500-509. [PMID: 30381984 DOI: 10.1177/1352458518807076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Personalized treatment is highly desirable in multiple sclerosis (MS). We believe that multidisciplinary measurements including clinical, functional and patient-reported outcome measures in combination with extensive patient profiling can enhance personalized treatment and rehabilitation strategies. We elaborate on four reasons behind this statement: (1) MS disease activity and progression are complex and multidimensional concepts in nature and thereby defy a one-size-fits-all description, (2) functioning, progression, treatment, and rehabilitation effects are interdependent and should be investigated together, (3) personalized healthcare is based on the dynamics of system biology and on technology that confirms a patient's fundamental biology and (4) inclusion of patient-reported outcome measures can facilitate patient-relevant healthcare. We discuss currently available multidisciplinary MS data initiatives and introduce joint actions to further increase the overall success. With this topical review, we hope to drive the MS community to invest in expanding towards more multidisciplinary and longitudinal data collection.
Collapse
Affiliation(s)
| | | | - Bart Van Wijmeersch
- Department of Neurology, Biomedical Research Institute, Hasselt University, Hasselt, Belgium/Rehabilitation & MS Center, Overpelt, Belgium
| | - Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Hasselt University, Hasselt, Belgium/Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute, University of Antwerp, Antwerp, Belgium
| | - Ilse Lamers
- Department of Neurology, Biomedical Research Institute, Hasselt University, Hasselt, Belgium/Rehabilitation & MS Center, Overpelt, Belgium
| | - Niels Hellings
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Veronica Popescu
- Department of Neurology, Biomedical Research Institute, Hasselt University, Hasselt, Belgium/Rehabilitation & MS Center, Overpelt, Belgium
| | - Christoph Thalheim
- External Affairs, European Multiple Sclerosis Platform, Brussels, Belgium
| | - Peter Feys
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| |
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW Chronic pain impacts millions of people in the USA. At the heart of the problem of chronic pain remains the complex psychosocial aspects associated with living with chronic pain. Given the overlap between chronic pain and mental health, a promising treatment approach is to improve how we integrate psychiatry into pain management. RECENT FINDINGS Treatment of chronic pain and comorbid mental health issues requires a multidisciplinary approach. Advancements in how pain is understood, especially centralized pain, have helped inform both pharmacological and behavioral interventions for pain. Given the growing concerns about the opioid epidemic and the lack of data supporting the use of opioids for long-term pain management, new treatment approaches are needed. Psychiatrist may be uniquely suited to help address comorbid mental health disorders and addiction in the context of chronic pain management. Addressing the psychiatric needs of chronic pain patients remains challenging and there is much room to improve how we address the complex issues associated with living with chronic pain. We believe psychiatrists are an important piece of the pain management puzzle.
Collapse
Affiliation(s)
- Jenna Goesling
- Department of Anesthesiology, Back & Pain Center, University of Michigan, Burlington Building 1, Suite 100, 325 E. Eisenhower Parkway, Ann Arbor, MI, 48108, USA.
| | - Lewei A Lin
- Department of Psychiatry, North Campus Research Complex, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
- Department of Veterans Affairs Healthcare System, North Campus Research Complex, VA Center for Clinical Management Research (CCMR), 2800 Plymouth Rd, Ann Arbor, MI, 48109, USA
| | - Daniel J Clauw
- Department of Anesthesiology, University of Michigan Health System, Domino's Farms, Lobby M, 24 Frank Lloyd Wright Dr, PO Box 385, Ann Arbor, MI, 48106, USA
| |
Collapse
|
20
|
Turner JR. Commissioner Gottlieb and the Crusade Against Opioid Abuse: Baptism by Fire. Ther Innov Regul Sci 2017; 51:400-403. [DOI: 10.1177/2168479017716636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|