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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 Prim 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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Mignogna J, Martin LA, Harik J, Hundt NE, Kauth M, Naik AD, Sorocco K, Benzer J, Cully J. "I had to somehow still be flexible": exploring adaptations during implementation of brief cognitive behavioral therapy in primary care. Implement Sci 2018; 13:76. [PMID: 29866141 PMCID: PMC5987469 DOI: 10.1186/s13012-018-0768-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 05/21/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers' perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol "fit" into their clinical practice. METHODS A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. RESULTS Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients' broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). CONCLUSIONS The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the "fit" into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. TRIAL REGISTRATION ClinicalTrials.gov, NCT01149772.
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Affiliation(s)
- Joseph Mignogna
- VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA Health Care System, 4800 Memorial Drive (151C), Waco, TX, 76711, USA.
- Department of Psychiatry and Behavioral Sciences, Texas A&M University Health Science Center, Temple, TX, USA.
| | - Lindsey Ann Martin
- Houston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- South Central Mental Illness Research, Education and Clinical Center (SC MIRECC), Houston, TX, USA
| | - Juliette Harik
- National Center for Posttraumatic Stress Disorder, Executive Division, White River Junction, VT, USA
| | - Natalie E Hundt
- Houston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- South Central Mental Illness Research, Education and Clinical Center (SC MIRECC), Houston, TX, USA
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Michael Kauth
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- South Central Mental Illness Research, Education and Clinical Center (SC MIRECC), Houston, TX, USA
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Aanand D Naik
- Houston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kristen Sorocco
- Oklahoma City VA Health Care System, Oklahoma City, OK, USA
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Justin Benzer
- VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA Health Care System, 4800 Memorial Drive (151C), Waco, TX, 76711, USA
- Department of Psychiatry, Dell Medical School, University of Texas, Austin, TX, USA
| | - Jeffrey Cully
- Houston VA Health Services Research and Development Center of Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- South Central Mental Illness Research, Education and Clinical Center (SC MIRECC), Houston, TX, USA
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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