1
|
Bohm MK, Siwakoti L, Nahin RL. Treatment Among Commercial and Medicaid-insured Adults with Incident Chronic Pain Episodes. THE JOURNAL OF PAIN 2024:104667. [PMID: 39271034 DOI: 10.1016/j.jpain.2024.104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 08/20/2024] [Accepted: 08/31/2024] [Indexed: 09/15/2024]
Abstract
Analyses of healthcare data can reveal utilization of treatment options that comprise a multidisciplinary approach to chronic pain management. This retrospective cohort study aimed to characterize treatments among commercially vs. Medicaid-insured adults with incident episodes of chronic pain. We used MarketScan® data to identify patients with diagnoses for conditions associated with chronic pain, assess procedure codes that align with broad categories of treatment options, and compare receipt of treatments by insurance type. Among enrollees aged ≥18 years, 4,254,818 adults with commercial insurance and 583,369 with Medicaid met continuous enrollment criteria and had no chronic pain episodes in 2017. Among patients with incident chronic pain episodes during 2018-2020, we determined the proportions receiving different categories of treatment options during the year following diagnosis. Cohen's h determined meaningful differences by insurance. Study cohorts included 1,095,358 commercial (mean [SD] age, 47.3 [13.3] years; 54.3% women) and 176,607 Medicaid adults (38.1 [12.7] years; 70.6% women) with incident chronic pain episodes during 2018-2020. More commercial than Medicaid patients received restorative therapies such as physical therapy (38.6% vs. 19.2%), complementary or integrative care such as chiropractic treatment (31.1% vs.9.0%), and two or more different types of nonmedication treatment procedures (34.1% vs.16.3%). Median days to treatments were shorter for commercial patients. Disparities in the provision, patterns and timing of treatments by insurance suggest differential access to the full range of treatment options early during the course of care and identify opportunities to align coverage and reimbursement policies with current practice guidelines. PERSPECTIVE: This analysis of medical claims for patients with incident chronic pain episodes found disparities in the provision, patterns and timing of treatments by insurance type. These results suggest differential access to evidence-based treatment options early during care and identify opportunities to align coverage and reimbursement policies with current practice guidelines.
Collapse
Affiliation(s)
- Michele K Bohm
- Office of Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H 21-11, Atlanta, Georgia 30329, USA.
| | - Lila Siwakoti
- Global Health Center, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H 21-09, Atlanta, Georgia, 30329, USA.
| | - Richard L Nahin
- National Center for Complementary and Integrative Health, National Institutes of Health, 9000 Rockville Pike, Bethesda, Maryland 20892-5475, USA.
| |
Collapse
|
2
|
Liao TH, Rindfleisch JA, Howard KP, Castellani M, Noyes SG. Advancing a new model of collaborative practice: a decade of Whole Health interprofessional education across Veterans Health Administration. BMC MEDICAL EDUCATION 2024; 24:987. [PMID: 39256757 PMCID: PMC11389288 DOI: 10.1186/s12909-024-05945-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 08/22/2024] [Indexed: 09/12/2024]
Abstract
Large-scale implementation of interprofessional education across the United States Veterans Health Administration has supported advancement of a new model of collaborative practice, the Whole Health System, centering on the patient and what matters most to them. Other health care systems can consider similar educational efforts for health care transformation.
Collapse
Affiliation(s)
- Theresa H Liao
- Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC, USA.
- Section of General Medicine, Portland VA, Portland, OR, USA.
| | - J Adam Rindfleisch
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, USA
| | - Kelly Peyton Howard
- US Army Training and Doctrine Command, Holistic Health and Fitness Directorate, Richmond, Virginia, USA
| | - Marc Castellani
- Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC, USA
| | - Sara Grimsgaard Noyes
- Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC, USA
| |
Collapse
|
3
|
Edmond SN, Becker WC. Focus on Function: Aligning Patient Values with Clinician Reassessment of Long-Term Opioid Therapy. J Gen Intern Med 2024; 39:2108-2109. [PMID: 38806796 PMCID: PMC11306475 DOI: 10.1007/s11606-024-08821-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/14/2024] [Indexed: 05/30/2024]
Affiliation(s)
- Sara N Edmond
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA.
- Yale School of Medicine, New Haven, CT, USA.
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
4
|
Haun JN, Schneider T, Ballistrea LM, McMahon-Grenz J, Melillo C, Benzinger R, Paykel JM. Veterans' lived experiences with the VA's Whole Health system and perceived impact on dimensions of wellness. Explore (NY) 2024; 20:554-561. [PMID: 38184376 DOI: 10.1016/j.explore.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/12/2023] [Accepted: 12/20/2023] [Indexed: 01/08/2024]
Abstract
RESEARCH QUESTION What are the lived experiences and wellness related outcomes of veterans engaged in the Department of Veterans' Affairs (VA) Whole Health (WH) system of care? THEORETICAL FRAMEWORK This qualitative work was conducted with a pragmatic phenomenological approach to understand patients' lived experience within the WH system of care. Data were contextualized within a multi-dimensional wellness model. METHODOLOGY This descriptive quality improvement project used semi-structured telephone interviews. Interview script elicited veterans' WH participation experiences and perceived wellness related outcomes. CONTEXT Data were collected within a WH Service, at a large Veterans Health Administration Hospital in the Southeast United States. SAMPLE SELECTION Data were collected with a purposive sample of veterans that participated in at least 2 WH activities. DATA COLLECTION Patients were recruited by WH clinical team collaborators to participate in qualitative data collection. ANALYSIS AND INTERPRETATION Rapid content analysis and interpretation of results were conducted in alignment with dimensions of wellness constructs. MAIN RESULTS WH offers veterans' non-pharmacological tools to improve mental, physical, and social wellness. Participants (n = 50) represented the larger veteran population. Most veterans perceived a positive WH experience with improvement of three primary dimensions including mental and emotional, physical, and social wellness - impacts on other dimensions gleaned less perceived impact. Veterans reported adopting mindfulness and coping strategies, better mobility, pain management, and sleep quality, and enhanced social engagement. Even those who did benefit personally from all aspects of WH, felt the services are needed to support the larger veteran population. Reduced suicidal ideation and pain medication use emerged as a WH effect among approximately 10% of the sample.
Collapse
Affiliation(s)
- Jolie N Haun
- Research and Development Service, James A. Haley Veterans' Hospital, Research Service, 8900 Grand Oak Circle, Tampa, FL 33637, United States; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84132, United States
| | - Tali Schneider
- Research and Development Service, James A. Haley Veterans' Hospital, Research Service, 8900 Grand Oak Circle, Tampa, FL 33637, United States
| | - Lisa M Ballistrea
- Research and Development Service, James A. Haley Veterans' Hospital, Research Service, 8900 Grand Oak Circle, Tampa, FL 33637, United States
| | - Julie McMahon-Grenz
- Research and Development Service, James A. Haley Veterans' Hospital, Research Service, 8900 Grand Oak Circle, Tampa, FL 33637, United States
| | - Christine Melillo
- Research and Development Service, James A. Haley Veterans' Hospital, Research Service, 8900 Grand Oak Circle, Tampa, FL 33637, United States
| | - Rachel Benzinger
- Research and Development Service, James A. Haley Veterans' Hospital, Research Service, 8900 Grand Oak Circle, Tampa, FL 33637, United States.
| | - Jacquelyn M Paykel
- Whole Health Service, James A. Haley Veterans Hospital, Tampa, FL 33637, United States
| |
Collapse
|
5
|
Coffee Z, Cheng K, Slebodnik M, Mulligan K, Yu CH, Vanderah TW, Gordon JS. The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:794. [PMID: 38929040 PMCID: PMC11203961 DOI: 10.3390/ijerph21060794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/06/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.
Collapse
Affiliation(s)
- Zhanette Coffee
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
| | - Kevin Cheng
- College of Medicine, University of Arizona, Tucson, AZ 85721, USA;
| | | | - Kimberly Mulligan
- Veterans Health Administration, Central California, Fresno, CA 93706, USA
| | - Chong Ho Yu
- Department of Mathematics, Hawaii Pacific University, Honolulu, HI 96813, USA;
| | - Todd W. Vanderah
- Department of Pharmacology, Comprehensive Center for Pain and Addiction, University of Arizona, Tucson, AZ 85721, USA;
| | - Judith S. Gordon
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
| |
Collapse
|
6
|
Krause JS, DiPiro ND, Dismuke-Greer CE. Self-Reported Prescription Opioid Use Among Participants with Chronic Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2024; 30:131-139. [PMID: 38433739 PMCID: PMC10906374 DOI: 10.46292/sci23-00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Background Individuals with spinal cord injuries (SCI) experience high rates of prescription opioid use, yet there is limited data on frequency of opioid use and specific medications being taken. Objectives To examine the frequency of self-reported prescription opioid use among participants with SCI and the relationship with demographic, injury, and socioeconomic characteristics. Methods A cohort study of 918 adults with SCI of at least 1-year duration completed a self-report assessment (SRA) that indicated frequency of specific prescription opioid use based on the National Survey on Drug Use and Health (NSDUH). Results Forty-seven percent of the participants used at least one prescription opioid over the last year; the most frequently used was hydrocodone (22.1%). Nearly 30% used a minimum of one opioid at least weekly. Lower odds of use of at least one opioid over the past year was observed for Veterans (odds ratio [OR] = 0.60, 95% CI = 0.38, 0.96) and those with a bachelor's degree or higher (OR = 0.63, 95% CI = 0.44, 0.91). When restricting the analysis to use of at least one substance daily or weekly, lower odds of use was observed for those with a bachelor's degree or higher and those with income ranging from $25,000 to $75,000+. None of the demographic or SCI variables were significantly related to prescription opioid use. Conclusion Despite the widely established risks, prescription opioids were used daily or weekly by more than 28% of the participants. Usage was only related to Veteran status and socioeconomic status indicators, which were protective of use. Alternative treatments are needed for those with the heaviest, most regular usage.
Collapse
Affiliation(s)
- James S Krause
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Nicole D DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Clara E Dismuke-Greer
- Health Economics Resource Center, Veterans Affairs Palo Alto, Menlo Park, California
| |
Collapse
|
7
|
Courtney RE, Schadegg MJ, Bolton R, Smith S, Harden SM. Using a Whole Health Approach to Build Biopsychosocial-Spiritual Personal Health Plans for Veterans with Chronic Pain. Pain Manag Nurs 2024; 25:69-74. [PMID: 37839983 DOI: 10.1016/j.pmn.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/08/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
Chronic pain affects over 50 million Americans per year and costs society billions of dollars annually. It is widely accepted that the biomedical model is outdated and research on the biopsychosocial model of chronic pain has increased in recent years, concurrent with investigations into self-management of chronic pain. The Veterans Health Administration (VHA) has incorporated both of these approaches into their Whole Health System. This work describes the VHA Whole Health System, reviews the literature on alignment between the Whole Health System's Circle of Health and chronic pain, and explains how the VHA Whole Health model may be used as a method for organizing self-management strategies within a personal health plan in the context of chronic pain. Given the infusion of nurses throughout the healthcare system, nurses are in a unique position to champion this biopsychosocial-spiritual approach to care.
Collapse
Affiliation(s)
- Rena E Courtney
- PREVAIL Center for Chronic Pain, Salem, VA Health Care System, Salem, Virginia; Virginia Tech Carilion School of Medicine, Salem, Virginia.
| | - Mary J Schadegg
- NYU Grossman School of Medicine/NYU Langone Health, New York, New York
| | - Rendelle Bolton
- Center for Healthcare Organization and Implementation Research, Bedford VA Health Care System, Bedford, Massachusetts
| | - Stephanie Smith
- PREVAIL Center for Chronic Pain, Salem, VA Health Care System, Salem, Virginia
| | - Samantha M Harden
- Virginia Tech Carilion School of Medicine, Salem, Virginia; Virginia Tech, Blacksburg, Virginia
| |
Collapse
|
8
|
Bokhour BG, DeFaccio R, Gaj L, Barker A, Deeney C, Coggeshall S, Gelman H, Taylor SL, Thomas E, Zeliadt SB. Changes in Patient-Reported Outcomes Associated with Receiving Whole Health in the Veteran Health Administration (VHA)'s National Demonstration Project. J Gen Intern Med 2024; 39:84-94. [PMID: 37653207 PMCID: PMC10817883 DOI: 10.1007/s11606-023-08376-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Whole Health (WH) is a patient-centered model of care being implemented by the Veterans Health Administration. Little is known about how use of WH services impacts patients' health and well-being. OBJECTIVE We sought to assess the association of WH utilization with pain and other patient-reported outcomes (PRO) over 6 months. DESIGN A longitudinal observational cohort evaluation, comparing changes in PRO surveys for WH users and Conventional Care (CC) users. Inverse probability of treatment weighting was used to balance the two groups on observed demographic and clinical characteristics. PARTICIPANTS A total of 9689 veterans receiving outpatient care at 18 VA medical centers piloting WH. INTERVENTIONS WH services included goal-setting clinical encounters, Whole Health coaching, personal health planning, and well-being services. MAIN OUTCOME MEASURES The primary outcome was change in pain intensity and interference at 6 months using the 3-item PEG. Secondary outcomes included satisfaction, experiences of care, patient engagement in healthcare, and well-being. KEY RESULTS By 6 months,1053 veterans had utilized WH and 3139 utilized only CC. Baseline pain PEG scores were 6.2 (2.5) for WH users and 6.4 (2.3) for CC users (difference p = 0.028), improving by - 2.4% (p = 0.006) and - 2.3% (p < 0.001), respectively. In adjusted analyses, WH use was unassociated with greater improvement in PEG scores compared to CC - 1.0% (- 2.9%, 1.2%). Positive trends were observed for 8 of 15 exploratory outcomes for WH compared to CC. WH use was associated with greater improvements at 6 months in likelihood to recommend VA 2.0% (0.9%, 3.3%); discussions of goals 11.8% (8.2%, 15.5%); perceptions of healthcare interactions 2.5% (0.4%, 4.6%); and engagement in health behaviors 2.2% (0.3%, 3.9%). CONCLUSION This study provides early evidence supporting the delivery of WH patient-centered care services to improve veterans' experiences of and engagement in care. These are important first-line impacts towards the goals of better overall health and well-being outcomes for Veterans.
Collapse
Affiliation(s)
- Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Rian DeFaccio
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Anna Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Christine Deeney
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Scott Coggeshall
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Hannah Gelman
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, Department of Health Policy and Management, UCLA, Los Angeles, CA, USA
| | - Eva Thomas
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Steven B Zeliadt
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| |
Collapse
|
9
|
Nicosia FM, Purcell N, Bertenthal D, Usman H, Seidel I, McGrath S, Hildebrand C, McCarthy B, Seal KH. Evaluation of a New Integrative Health and Wellness Clinic for Veterans at the San Francisco VA Health Care System: A Mixed-Methods Pilot Study. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2024; 13:27536130241260034. [PMID: 38867941 PMCID: PMC11168048 DOI: 10.1177/27536130241260034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 06/14/2024]
Abstract
Objective The Integrative Health and Wellness Clinic (IHWC), established in 2019 at the San Francisco VA Health Care System, is an interdisciplinary clinic consisting of a medical provider, dietician, physical therapist, and psychologist trained in complementary and integrative health (CIH) following the VA Whole Health model of care. Veterans with complex chronic conditions seeking CIH and nonpharmacologic approaches are referred to the IHWC. This study evaluated the clinic's acceptability and feasibility among veteran patients and its preliminary impact on health and wellbeing, health-related goals, and use of CIH approaches. Methods Mixed methods were used to assess patient-reported outcomes and experiences with the IHWC. Participants completed surveys administered at baseline and 6-months and a subset completed a qualitative interview. Pre- and post-scores were compared using t-tests and chi-square tests. Results Thirty-five veterans completed baseline and 6-month follow up surveys. Of these, 13% were women; 24% < 50 years of age, and 44% identified as racial/ethnic minorities. Compared to baseline, at 6 months, there were significant (P < .05) improvements in overall health, physical health, perceived stress, and perceived helpfulness of clinicians in assisting with goal attainment; there was a trend toward improved mental health (P = .057). Interviews (n = 25) indicated satisfaction with the interdisciplinary clinical model, support of IHWC providers in goal attainment, and positive impact on physical and mental health. Areas for improvement included logistics related to scheduling of multiple IHWC providers and referrals to other CIH services. Conclusion Results revealed significant improvement in important clinical domains and satisfaction with interprofessional IHWC clinic providers, but also opportunities to improve clinic processes and care coordination. An interdisciplinary clinic focused on CIH and Whole Health is a feasible and acceptable model of care for veterans with complex chronic health conditions in the VA healthcare system.
Collapse
Affiliation(s)
- Francesca M Nicosia
- San Francisco VA Healthcare System, San Francisco, CA, USA
- Institute for Health & Aging, University of California, San Francisco, CA, USA
| | - Natalie Purcell
- San Francisco VA Healthcare System, San Francisco, CA, USA
- Departments of Social & Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Dan Bertenthal
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | - Hajra Usman
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | - Ilana Seidel
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | - Sarah McGrath
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | | | | | - Karen H Seal
- San Francisco VA Healthcare System, San Francisco, CA, USA
- Departments of Medicine & Psychiatry, University of California, San Francisco, CA, USA
| |
Collapse
|
10
|
Bolton RE, Mohr DC, Charns M, Herbst AN, Bokhour BG. Creating Whole Person Health Care Systems: Understanding Employee Perceptions of VAs Whole Health Cultural Transformation. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:813-821. [PMID: 37935016 DOI: 10.1089/jicm.2023.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Objective: Whole person health care, like that being implemented in the U.S. Veterans Health Administration (VHA), involves person-centered approaches that address what matters most to patients to achieve well-being beyond the biomedical absence of disease. As whole health (WH) approaches expand, their integration into clinical practice is predicated on health care employees reconceptualizing practice beyond find-it-fix-it medicine and embracing WH as a new philosophy of care. This study examined employee perspectives of WH and their integration of this approach into care. Design: We conducted a survey with responses from 1073 clinical and 800 nonclinical employees at 5 VHA WH Flagship sites about their perceptions and use of a WH approach. We used descriptive statistics to examine employees' support for WH and conducted thematic analysis to qualitatively explore their perceptions about this approach from free-text comments supplied by 475 respondents. Results: On structured survey items, employees largely agreed that WH was a valuable approach but were relatively less likely to have incorporated it into practice or report support within their organization for WH. Qualitative comments revealed varying conceptualizations of WH. While some respondents understood that WH represented a philosophical shift in care, many characterized WH narrowly as services. These conceptualizations contributed to lower perceived relevance, skepticism, and misgivings that WH diverted needed resources away from existing clinical services. Organizational context including leadership messaging, siloed structures, and limited educational opportunities reinforced these perceptions. Conclusions: Successfully transforming the culture of care requires a shift in mindset among employees and leadership alike. Employees' depictions didn't always reflect WH as a person-centered approach designed to engage patients to enhance their health and well-being. Without consistent leadership messaging and accessible training, opportunities to expand understandings of WH are likely to be missed. To promote WH transformation, additional attention is needed for employees to embrace this approach to care.
Collapse
Affiliation(s)
- Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Health Law, Policy, and Management Department, Boston University School of Public Health, Boston, MA, USA
| | - Martin Charns
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Health Law, Policy, and Management Department, Boston University School of Public Health, Boston, MA, USA
| | - Abigail N Herbst
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
11
|
Wang K, Fenton BT, Skanderson M, Black AC, Becker WC, Seng EK, Anthony SE, Guirguis AB, Altalib HH, Kimber A, Lorenze N, Scholten JD, Graham GD, Sandbrink F, Sico JJ. Changes in opioid prescribing in veterans with headache during the COVID-19 pandemic: A regression discontinuity in time analysis. Headache 2023; 63:1295-1303. [PMID: 37596904 DOI: 10.1111/head.14605] [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: 04/19/2023] [Revised: 06/08/2023] [Accepted: 06/14/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE To determine changes in opioid prescribing among veterans with headaches during the coronavirus disease of 2019 (COVID-19) pandemic by comparing the stay-at-home phase (March 15 to May 30, 2020) and the reopening phase (May 31 to December 31, 2020). BACKGROUND Opioid prescribing for chronic pain has declined substantially since 2016; however, changes in opioid prescribing during the COVID-19 pandemic among veterans with headaches remain unknown. METHODS This retrospective cohort study utilized regression discontinuity in time and difference-in-differences design to analyze veterans aged ≥18 years with a previous diagnosis of headache disorders and an outpatient visit to the Veterans Health Administration (VHA) during the study period. We measured the weekly number of opioid prescriptions, the number of days supplied, the daily dose in morphine milligram equivalents (MMEs), and the number of prescriptions with ≥50 morphine equivalent daily doses (MEDD). RESULTS A total of 81,376 veterans were analyzed with 589,950 opioid prescriptions. The mean (SD) age was 51.6 (13.5) years, 57,242 (70.3%) were male, and 53,464 (65.7%) were White. During the pre-pandemic period, 323.6 opioid prescriptions (interquartile range 292.1-325.8) were dispensed weekly, with an median (IQR) of 24.1 (24.0-24.4) days supplied and 31.8 (31.2-32.5) MMEs. Transition to stay-at-home was associated with a 7.7% decrease in the number of prescriptions (incidence rate ratio [IRR] 1.077, 95% confidence interval [CI] 0.866-0.984) and a 9.8% increase in days supplied (IRR 1.098, 95% CI 1.078-1.119). Similar trends were observed during the reopening period. Subgroup analysis among veterans on long-term opioid therapy also revealed 1.7% and 1.4% increases in days supplied during the stay-at-home (IRR 1.017, 95% CI 1.009-1.025) and reopening phase (IRR 1.014, 95% CI 1.007-1.021); however, changes in the total number of prescriptions, MME/day, or the number of prescriptions >50 MEDD were insignificant. CONCLUSION Prescription opioid access was maintained for veterans within VHA during the pandemic. The de-escalation of opioid prescribing observed prior to the pandemic was not seen in our study.
Collapse
Affiliation(s)
- Kaicheng Wang
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Brenda T Fenton
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Melissa Skanderson
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
| | - Anne C Black
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - William C Becker
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth K Seng
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sarah E Anthony
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Hamada H Altalib
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Addison Kimber
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nancy Lorenze
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joel D Scholten
- Physical Medicine and Rehabilitation Service, Washington DC VA Medical Center, Washington, District of Columbia, USA
| | - Glenn D Graham
- Department of Neurology, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Friedhelm Sandbrink
- Pain Management Specialty Services, Washington DC VA Medical Center, Washington, District of Columbia, USA
| | - Jason J Sico
- Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, US Department of Veterans Affairs, Orange, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
12
|
Kehne A, Bernstein SJ, Thomas J, Bicket MC, Bohnert ASB, Madden EF, Powell VD, Lagisetty P. Improving Access to Care for Patients Taking Opioids for Chronic Pain: Recommendations from a Modified Delphi Panel in Michigan. J Pain Res 2023; 16:2321-2330. [PMID: 37456356 PMCID: PMC10348368 DOI: 10.2147/jpr.s406034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose About 5-8 million US patients take long-term opioid therapy for chronic pain. In the context of policies and guidelines instituted to reduce inappropriate opioid prescribing, abrupt discontinuations in opioid prescriptions have increased and many primary care clinics will not prescribe opioids for new patients, reducing access to care. This may result in uncontrolled pain and other negative outcomes, such as transition to illicit opioids. The objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients. Participants and Methods We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020-January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority. Results The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities. Conclusion Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access.
Collapse
Affiliation(s)
- Adrianne Kehne
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Steven J Bernstein
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Thomas
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mark C Bicket
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Erin Fanning Madden
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Victoria D Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
| | - Pooja Lagisetty
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
13
|
Hale-Gallardo J, Kreider CM, Castañeda G, LeBeau K, Varma DS, Knecht C, Cowper Ripley D, Jia H. Meeting the Needs of Rural Veterans: A Qualitative Evaluation of Whole Health Coaches' Expanded Services and Support during COVID-19. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13447. [PMID: 36294023 PMCID: PMC9602744 DOI: 10.3390/ijerph192013447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/23/2022] [Accepted: 10/06/2022] [Indexed: 06/16/2023]
Abstract
The purpose of this qualitative study was to explore perspectives of Whole Health (WH) coaches at the Veterans Health Administration (VHA) on meeting the needs of rural Veterans during the COVID-19 pandemic. The evaluation design employed a qualitative description approach, employing focus groups and in-depth interviews with a convenience sample of WH coaches across the VHA system. Fourteen coaches who work with rural Veterans participated in either one of three focus groups, individual interviews, or both. The focus group data and in-depth interviews were analyzed separately using thematic analysis, and findings were then merged to compare themes across both datasets. Four primary themes were identified: bridging social risk factors for rural Veterans, leveraging technology to stay connected with Veterans at-a-distance, redirecting Veterans to alternate modes of self-care, and maintaining flexibility in coaching role during COVID-19. One overarching theme was also identified following a post-hoc analysis driven by interdisciplinary team discussion: increased concerns for Veteran mental health during COVID-19. Coaches reported using a variety of strategies to respond to the wide-ranging needs of rural Veterans during the pandemic. Implications of findings for future research and practice are discussed.
Collapse
Affiliation(s)
- J Hale-Gallardo
- Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Office of Rural Health, Veterans Health Administration, Salt Lake City, UT 84148, USA
| | - Consuelo M Kreider
- Veterans Rural Health Resource Center-Gainesville (VRHRC-GNV), Office of Rural Health, Veterans Health Administration, Gainesville, FL 32601, USA
- Department of Occupational Therapy, University of Florida, Gainesville, FL 32611, USA
| | - Gail Castañeda
- Veterans Rural Health Resource Center-Gainesville (VRHRC-GNV), Office of Rural Health, Veterans Health Administration, Gainesville, FL 32601, USA
| | - Kelsea LeBeau
- Veterans Rural Health Resource Center-Gainesville (VRHRC-GNV), Office of Rural Health, Veterans Health Administration, Gainesville, FL 32601, USA
| | - Deepthi S Varma
- Veterans Rural Health Resource Center-Gainesville (VRHRC-GNV), Office of Rural Health, Veterans Health Administration, Gainesville, FL 32601, USA
- Department of Epidemiology, University of Florida, Gainesville, FL 32611, USA
| | - Cheri Knecht
- Veterans Rural Health Resource Center-Gainesville (VRHRC-GNV), Office of Rural Health, Veterans Health Administration, Gainesville, FL 32601, USA
| | - Diane Cowper Ripley
- Veterans Rural Health Resource Center-Gainesville (VRHRC-GNV), Office of Rural Health, Veterans Health Administration, Gainesville, FL 32601, USA
| | - Huanguang Jia
- Department of Biostatistics, University of Florida, Gainesville, FL 32611, USA
| |
Collapse
|