Implementation, intervention, and downstream costs for implementation of a multidisciplinary complex pain clinic in the Veterans Health Administration.

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.

A Tool to Identify and Engage Patients on Risky Opioid Regimens.

BACKGROUND: Concerns around opioid safety for patients living with chronic pain have led to a growing number of collaborative and multimodal pain care initiatives. A major challenge in these efforts has been identifying and engaging patients on high-risk opioid regimens in a timely manner. OBJECTIVES: In this clinical informatics case report, we describe the development and implementation of a web-based tool to support providers as they implement an integrated pain support clinical initiative at primary care clinics across three health care systems. METHODS: The tool identifies patients on risky opioid medication regimens and generates autopopulated patient outreach letters. It contains three core functions that: (1) identify patients prescribed high-dose opioids or coprescribed opioids and benzodiazepines, (2) generate automated letters for patients with an upcoming primary care appointment, and (3) allow clinic staff to write back to a database to track outreach and referrals. Qualitative stakeholder feedback was gathered through interviews and user testing to assess perceived usefulness and ease of use of the tool. RESULTS: Over a 24-month period, the tool identified 1,125 patients prescribed risky medication regimens and generated 1,315 total letters as some patients became reeligible. Stakeholder feedback revealed that the tool was useful to quickly find patients on risky medication regimens and efficient in generating prepopulated letters that could be mailed in large batches. Additional feedback led to iterative refinements and improved system capabilities that varied across clinics. CONCLUSION: Deploying clinical informatics tools that prioritize, engage, and track high-risk patient populations supports reduction of risky medication regimens. Such tools can reduce workload burden on busy primary care staff, particularly during implementation studies, and enhance patient-centered care through the use of direct-to-consumer outreach.

Patient and provider perspectives of personal health record use: a multisite qualitative study in HIV care settings.

Use of tethered personal health records (PHRs) can streamline care, reduce unnecessary care utilization, and improve health outcomes for people living with human immunodeficiency virus (HIV). Providers play a role in influencing patients' decision to adopt and use PHRs. To explore patient and provider acceptance and use of PHRs in an HIV care setting. We used a qualitative study design guided by the Unified Theory of Acceptance and Use of Technology. Participants included providers of HIV care, patients living with HIV, and PHR coordinating and support staff in the Veterans Health Administration (VA). Interviews were analyzed using directed content analysis. We interviewed providers (n = 41), patients living with HIV (n = 60), and PHR coordinating and support staff (n = 16) at six VA Medical Centers between June and December 2019. Providers perceived PHR use could enhance care continuity, appointment efficiency, and patient engagement. Yet, some expressed concerns that patient PHR use would increase provider workload and detract from clinical care. Concerns about poor PHR interoperability with existing clinical tools further eroded acceptance and use of PHRs. PHR use can enhance care for patients with HIV and other complex, chronic conditions. Negative provider attitudes toward PHRs may impact providers' encouragement of use among patients, consequently limiting patient uptake. Multipronged interventions at the individual, institutional, and system level are needed to enhance PHR engagement among both providers and patients.

Personal health records, also known as patient portals, allow patients to see personal health information on their computers or phones. Patients who use portals can address many health needs without going to their doctor's office. In our study, we wanted to understand why patients living with human immunodeficiency virus (HIV) may choose not to use patient portals. We talked to 60 patients with HIV, 41 medical providers, and 16 portal support staff from six United States Veterans Affairs (VA) hospitals. We learned that providers influence patient decisions to use patient portals­patients were more likely to consider using a patient portal when their providers talked to them about it. However, some providers felt they did not have the time to talk about portals. They also did not feel prepared to support patients who needed help using them. Providers were more likely to talk about patient portals if they saw their benefits and if they felt their patients use them. Some patients were concerned about the security of the information on their patient portals. To increase portal use among patients with HIV, hospitals should address the concerns that patients and providers have about portals while also highlighting the benefits of portal use.