Flipping the Pain Care Model: A Sociopsychobiological Approach to High-Value Chronic Pain Care.

OBJECTIVE: Much of the pain care in the United States is costly and associated with limited benefits and significant harms, representing a crisis of value. We explore the current factors that lead to low-value pain care within the United States and provide an alternate model for pain care, as well as an implementation example for this model that is expected to produce high-value pain care. METHODS: From the perspective of aiming for high-value care (defined as care that maximizes clinical benefit while minimizing harm and cost), we describe the current evidence practice gap (EPG) for pain care in the United States, which has developed as current clinical care diverges from existing evidence. A discussion of the biomedical, biopsychosocial, and sociopsychobiological (SPB) models of pain care is used to elucidate the origins of the current EPG and the unconscious factors that perpetuate pain care systems despite poor results. RESULTS: An interprofessional pain team within the Veterans Health Administration is described as an example of a pain care system that has been designed to deliver high-value pain care and close the EPG by implementing the SPB model. CONCLUSIONS: Adopting and implementing a sociopsychobiological model may be an effective approach to address the current evidence practice gap and deliver high-value pain care in the United States. The Phoenix VA Health Care System's Chronic Pain Wellness Center may serve as a template for providing high-value, evidence-based pain care for patients with high-impact chronic pain who also have medical, mental health, and opioid use disorder comorbidities.

Information-seeking in cancer survivors: application of the Comprehensive Model of Information Seeking to HINTS 2007 data.

Despite health care providers' best efforts, many cancer survivors have unmet informational and support needs. As a result, cancer survivors often have to meet these needs themselves, and how they approach this process is poorly understood. The authors aimed to validate and extend the Comprehensive Model of Information Seeking to examine information-seeking behaviors across a variety of channels of information delivery and to explore the impact of health-related factors on levels of information seeking. The data of 459 cancer survivors were drawn from the National Cancer Institute's 2007 Health Information National Trends Survey. Structural equation modeling was used to evaluate the associations among health-related factors, information-carrier factors, and information-seeking behavior. Results confirmed direct effects of direct experience, salience, and information-carrier characteristics on information-carrier utility. However, the direct impact of demographics and beliefs on information-carrier utility was not confirmed, nor were the effects of information-carrier factors on information-seeking behavior. Contrary to expectations, salience had direct effect on information-seeking behavior and on information-carrier characteristics. These results show that understanding antecedents of information seeking will inform the development and implementation of systems of care that will help providers better meet cancer survivors' needs.

Didactic dissonance-embracing the tension between classroom and clinical education.

The United States is undergoing a transformation in the way pain is viewed and treated. This transformation affects pain education, as some degree of disconnect will be expected between what is taught in classroom settings and what learners observe in clinical settings. We term this disconnect "didactic dissonance" and propose a novel process to harness it as a learning tool to further pain education. Based on principles of transformative learning theory, we describe a structured, three-step process beginning with (1) priming learners to recognize didactic dissonance and identify specific examples from their education, followed by (2) encouraging learners to search the primary literature to resolve observed dissonance and reflect on the system factors that created and perpetuated the disconnect, and then (3) providing an opportunity for learner reflection and planning for how they will address similar situations in future practice and teaching environments. Fostering an environment conducive to learning-through modeling the intellectual virtues of curiosity, humility, and creativity-is a critical task for educators when implementing this process. Recognizing challenges faced by educators in both classroom and clinical settings, it may be a more feasible first step to integrate the concept of didactic dissonance into existing curricular elements. For programs able to implement the full three-step process, a discussion guide along with an example of a facilitated discussion have been provided. While proposed in the context of pain education, this transformational approach can be utilized across all topics in medical education to foster autonomous lifelong learning.

Flipping the hidden curriculum to transform pain education and culture.

Though long-sought, transformation of pain management practice and culture has yet to be realized. We propose both a likely cause-entrenchment in a biomedical model of care that is observed and then replicated by trainees-and a solution: deliberately leveraging the hidden curriculum to instead implement a sociopsychobiological (SPB) model of care. We make use of Implicit Bias Recognition and Management, a tool that helps teams to first recognize and "surface" whatever is implicit and to subsequently intervene to change whatever is found to be lacking. We describe how a practice might use iterations of recognition and intervention to move from a biomedical to a SPB model by providing examples from the Chronic Pain Wellness Center in the Phoenix Veterans Affairs Health Care System. As pain management practitioners and educators collectively leverage the hidden curriculum to provide care in the SPB model, we will not only positively transform our individual practices but also pain management as a whole.

Program Evaluation: exploring health disparities that impact chronic pain referrals within a VA Health Care System.

Introduction: The present Program Evaluation study examines sociodemographic characteristics of Veterans in the Phoenix VA Health Care System who have back pain, and specifically the likelihood of those characteristics being associated with a referral to the Chronic Pain Wellness Center (CPWC) in the year 2021. We examined the following characteristics: Race/ethnicity, gender, age, mental health diagnosis, substance use disorder diagnosis, and service-connected diagnosis. Methods: Our study used cross sectional data from the Corporate Data Warehouse for 2021. 13624 records had complete data for the variables of interest. Univariate and multivariate logistic regression was used to determine the likelihood of patients' being referred to the Chronic Pain Wellness Center. Results: The multivariate model found under-referral to be significant for younger adults and for patients who identified as Hispanic/Latinx, Black/African American, or Native American/Alaskan. Those with depressive disorders and opioid use disorders, on the other hand, were found to be more likely to be referred to the pain clinic. Other sociodemographic characteristics were not found to be significant. Discussion: Study limitations include the use of cross-sectional data, which cannot determine causality, and the inclusion of patients only if the ICD-10 codes of interest were recorded for an encounter in 2021 (i.e., a prior history of a particular diagnosis was not captured). In future efforts, we plan to examine, implement, and track the impact of interventions designed to mitigate these identified disparities in access to chronic pain specialty care.

Neuropsychological tests for predicting cognitive decline in older adults.

AIM: To determine neuropsychological tests likely to predict cognitive decline. METHODS: A sample of nonconverters (n = 106) was compared with those who declined in cognitive status (n = 24). Significant univariate logistic regression prediction models were used to create multivariate logistic regression models to predict decline based on initial neuropsychological testing. RESULTS: Rey-Osterrieth Complex Figure Test (RCFT) Retention predicted conversion to mild cognitive impairment (MCI) while baseline Buschke Delay predicted conversion to Alzheimer's disease (AD). Due to group sample size differences, additional analyses were conducted using a subsample of demographically matched nonconverters. Analyses indicated RCFT Retention predicted conversion to MCI and AD, and Buschke Delay predicted conversion to AD. CONCLUSION: Results suggest RCFT Retention and Buschke Delay may be useful in predicting cognitive decline.