Improving shared decision-making around antimicrobial-prescribing during the end-of-life period: a qualitative study of Veterans, their support caregivers and their providers.

Objective: Antimicrobials are frequently used for palliation during end-of-life care, but adverse effects, such as antimicrobial resistance, are a concern. Shared decision-making is beneficial in end-of-life care conversations to help align antimicrobial-prescribing with patient preferences. However, there is limited data regarding optimal incorporation of antimicrobial-prescribing discussions into shared decision-making conversations. We explored healthcare provider, patient, and support caregiver (eg, family member/friend) perceptions of barriers and facilitators to discussing antimicrobial-prescribing during the end-of-life period. Design: Qualitative study. Participants: Healthcare providers; palliative care/hospice care patients/caregivers. Methods: We conducted semi-structured interviews on shared attitudes/beliefs about antimicrobial-prescribing during end-of-life patient care at one acute-care and one long-term-care facility. Interviews were analyzed for thematic content. Results: Fifteen providers and 13 patients/caregivers completed interviews. Providers recognized the potential benefit of leveraging shared decision-making to guide antimicrobial-prescribing decisions. Barriers included limited face-to-face time with the patient and uncertainty of end-of-life prognosis. Patients/caregivers cited trust, comprehension, and feeling heard as important characteristics which act as facilitators in fostering effective shared decision-making around antimicrobial use. Communication in which providers ensure patients are involved in shared decision-making discussions could be increased to ensure patients and their providers develop a mutually agreeable care plan. Conclusions: Shared decision-making is a practice that can guide antimicrobial-prescribing decisions during end-of-life care, thus potentially minimizing antimicrobial-related adverse effects. Our findings highlight opportunities for increased shared decision-making around antimicrobial use during end-of-life care. Interventions designed to address the identified barriers to shared decision-making have the potential to improve antimicrobial-prescribing practices at end-of-life.

Qualitative interview study of strategies to support healthcare personnel mental health through an occupational health lens.

BACKGROUND: Employee Occupational Health ('occupational health') clinicians have expansive perspectives of the experience of healthcare personnel. Integrating mental health into the purview of occupational health is a newer approach that could combat historical limitations of healthcare personnel mental health programmes, which have been isolated and underused. OBJECTIVE: We aimed to document innovation and opportunities for supporting healthcare personnel mental health through occupational health clinicians. This work was part of a national qualitative needs assessment of employee occupational health clinicians during COVID-19 who were very much at the centre of organisational responses. DESIGN: This qualitative needs assessment included key informant interviews obtained using snowball sampling methods. PARTICIPANTS: We interviewed 43 US Veterans Health Administration occupational health clinicians from 29 facilities. APPROACH: This analysis focused on personnel mental health needs and opportunities, using consensus coding of interview transcripts and modified member checking. KEY RESULTS: Three major opportunities to support mental health through occupational health involved: (1) expanded mental health needs of healthcare personnel, including opportunities to support work-related concerns (eg, traumatic deployments), home-based concerns and bereavement (eg, working with chaplains); (2) leveraging expanded roles and protocols to address healthcare personnel mental health concerns, including opportunities in expanding occupational health roles, cross-disciplinary partnerships (eg, with employee assistance programmes (EAP)) and process/protocol (eg, acute suicidal ideation pathways) and (3) need for supporting occupational health clinicians' own mental health, including opportunities to address overwork/burn-out with adequate staffing/resources. CONCLUSIONS: Occupational health can enact strategies to support personnel mental health: to structurally sustain attention, use social cognition tools (eg, suicidality protocols or expanded job descriptions); to leverage distributed attention, enhance interdisciplinary collaboration (eg, chaplains for bereavement support or EAP) and to equip systems with resources and allow for flexibility during crises, including increased staffing.

Meeting high-risk patient pain care needs through intensive primary care: a secondary analysis.

OBJECTIVE: Chronic pain disproportionately affects medically and psychosocially complex patients, many of whom are at high risk of hospitalisation. Pain prevalence among high-risk patients, however, is unknown, and pain is seldom a focus for improving high-risk patient outcomes. Our objective is to (1) evaluate pain frequency in a high-risk patient population and (2) identify intensive management (IM) programme features that patients and providers perceive as important for promoting patient-centred pain care within primary care (PC)-based IM. DESIGN: Secondary observational analysis of quantitative and qualitative evaluation data from a multisite randomised PC-based IM programme for high-risk patients. SETTING: Five integrated local Veterans Affairs (VA) healthcare systems within distinct VA administrative regions. PARTICIPANTS: Staff and high-risk PC patients in the VA. INTERVENTION: A multisite randomised PC-based IM programme for high-risk patients. OUTCOME MEASURES: (a) Pain prevalence based on VA electronic administrative data and (b) transcripts of interviews with IM staff and patients that mentioned pain. RESULTS: Most (70%, 2593/3723) high-risk patients had at least moderate pain. Over one-third (38%, 40/104) of the interviewees mentioned pain or pain care. There were 89 pain-related comments addressing IM impacts on pain care within the 40 interview transcripts. Patient-identified themes were that IM improved communication and responsiveness to pain. PC provider-identified themes were that IM improved workload and access to expertise. IM team member-identified themes were that IM improved pain care coordination, facilitated non-opioid pain management options and mitigated provider compassion fatigue. No negative IM impacts on pain care were mentioned. CONCLUSIONS: Pain is common among high-risk patients. Future IM evaluations should consider including a focus on pain and pain care, with attention to impacts on patients, PC providers and IM teams.

Disparities in Preoperative Goals of Care Documentation in Veterans.

Importance: Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk. Objective: To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans. Design, Setting, and Participants: This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022. Exposures: Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors. Main Outcomes and Measures: Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression. Results: In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001). Conclusions and Relevance: In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.

Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans.

CONTEXT: Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES: To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS: We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS: Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION: The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.

Serious illness care quality during COVID-19: Identifying improvement opportunities in narrative reports from a National Bereaved Family Survey.

BACKGROUND: COVID-19 significantly impacted care delivery to seriously ill patients, especially around including family and caregivers in patient care. AIM: Based on routinely collected bereaved family reports, actionable practices were identified to maintain and improve care in the last month of life, with potential application to all seriously ill patients. DESIGN: The Veterans Health Administration's Bereaved Family Survey is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents; the survey includes multiple structured items as well as space for open narrative responses. The responses were analyzed using qualitative content analysis with dual review. SETTING/PARTICIPANTS: Between February 2020 and March 2021, there were 5372 responses to the free response questions of which 1000 (18.6%) responses were randomly selected. The 445 (44.5%) responses from 377 unique individuals included actionable practices. RESULTS: Bereaved family members and caregivers identified four opportunities with a total of 32 actionable practices. Opportunity 1: Facilitate the use of video communication, included four actionable practices. Opportunity 2: Provide timely and accurate responses to family concerns, included 17 actionable practices. Opportunity 3: Accommodate family/caregiver visitation, included eight actionable practices. Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit, included three actionable practices. CONCLUSION: The findings from this quality improvement project are applicable during a pandemic, but also translate to improving the care of seriously ill patients in other circumstances, such as when family members or caregivers are geographically distant from a loved one during the last weeks of life.

Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations.

Importance: Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery. Objective: To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery. Design, Setting, and Participants: This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022. Exposure: Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more. Main Outcomes and Measures: Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation. Results: Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47). Conclusions and Relevance: Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.

"It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period.

CONTEXT: Palliative care (PC) interventions improve quality outcomes for surgical patients, yet they are underutilized in the perioperative period. Developing cross-disciplinary provider relationships increases PC consults. However, the attributes of collaborative relationships and how they evolve are unclear. OBJECTIVES: To identify perceptions of PC providers and surgeons on how collaborative cross-disciplinary relationships are built and maintained in the perioperative period. METHODS: This cross-sectional multiphase qualitative study included 23 semistructured interviews with 10 PC teams (20 providers) and 13 surgeons at geographically distributed Veteran Health Administration (VHA) sites. An analytic approach relied on team-based thematic analysis with a dual review (Krippendorf α above 0.8). RESULTS: Respondents defined successful collaborative work relationships between PC and surgeons as having the following features: 1) mutual trust; 2) mutual respect; 3) perceived usefulness; 4) shared clinical objectives; 5) effective communication; and 6) organizational enablers. In addition, the analysis elucidated a framework of six strategies for developing collaborative relationships between PC and surgical teams in the perioperative period: 1) being present, available, and responsive; 2) understanding roles; 3) establishing communication; 4) recognizing an intermediary and connecting role of supporting team members; 5) working as a team; and 6) building on previous experiences. CONCLUSION: The study informs future interventions to improve the quality of care for seriously ill patients by better-involving PC in the perioperative period. Future work will extend this approach to incorporate the perspectives of patients on their providers' collaboration and how it impacts patient-related outcomes at the intersection of PC and surgery.

Using Family Narrative Reports to Identify Practices for Improving End-of-Life Care Quality.

CONTEXT: Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement. OBJECTIVES: To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care. METHODS: We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation. RESULTS: Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation. CONCLUSION: Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.

Protecting the healthcare workforce during COVID-19: a qualitative needs assessment of employee occupational health in the US national Veterans Health Administration.

OBJECTIVE: Early in the COVID-19 pandemic, US Veterans Health Administration (VHA) employee occupational health (EOH) providers were tasked with assuming a central role in coordinating employee COVID-19 screening and clearance for duty, representing entirely novel EOH responsibilities. In a rapid qualitative needs assessment, we aimed to identify learnings from the field to support the vastly expanding role of EOH providers in a national healthcare system. METHODS: We employed rapid qualitative analysis of key informant interviews in a maximal variation sample on the parameters of job type, rural versus urban and provider gender. We interviewed 21 VHA EOH providers between July and December 2020. This sample represents 15 facilities from diverse regions of the USA (large, medium and small facilities in the Mid-Atlantic; medium sites in the South; large facilities in the West and Pacific Northwest). RESULTS: Five interdependent needs included: (1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (eg, employee-facing electronic health records and coordinated databases); (2) mechanisms for information sharing across settings (eg, VHA listserv), especially for changing policy and protocols; (3) sufficiently resourced staffing using detailing to align EOH needs with human resource capital; (4) connected and resourced local and national leaders; and (5) strategies to support healthcare worker mental health.Our identified facilitators for EOH assuming new challenging and dynamically changing roles during COVID-19 included: (A) training or access to expertise; (B) existing mechanisms for information sharing; (C) flexible and responsive staffing; and (D) leveraging other institutional expertise not previously affiliated with EOH (eg, chaplains to support bereavement). CONCLUSIONS: Our needs assessment highlights local and system level barriers and facilitators of EOH assuming expanded roles during COVID-19. Integrating changes both within and across systems and with alignment of human capital will enable EOH preparedness for future challenges.

Opportunities for improving opioid disposal practices in the Veterans Health Administration.

PURPOSE: The potentially vast supply of unused opioids in Americans' homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement. METHODS: We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities. RESULTS: While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic. CONCLUSION: A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.

Developing Unique Insights From Narrative Responses to Bereaved Family Surveys.

CONTEXT: Although bereaved family surveys (BFS) are routinely used quantitatively for quality assessment, open-ended and narrative responses are rarely systematically analyzed. Analysis of narrative responses may identify opportunities for improving end-of-life (EOL) care delivery. OBJECTIVES: To highlight the value of routine and systematic analysis of narrative responses and to thematically summarize narrative responses to the BFS of Veterans Affairs. METHODS: We analyzed more than 4600 open-ended responses to the BFS for all 2017 inpatient decedents across Veterans Affairs facilities. We used a descriptive qualitative approach to identify major themes. RESULTS: Thematic findings clustered into three domains: patient needs, family needs, and facility and organizational characteristics. Patient needs include maintenance of veteran's hygiene, appropriately prescribing medications, adhering to patient wishes, physical presence in patient's final hours, and spiritual and religious care at EOL. Family and caregiver needs included enhanced communication with the patient's care team, assistance with administrative and logistical challenges after death, emotional support, and displays of respect and gratitude for the patient's life. Facility and organizational characteristics included care team coordination, optimal staffing, the importance of nonclinical staff to care, and optimizing facilities to be welcoming, equipped for individuals with disabilities, and able to provide high-quality food. CONCLUSION: Systematic analysis of narrative survey data yields unique findings not routinely available through quantitative data collection and analysis. Organizations may benefit from the collection and regular analysis of narrative survey responses, which facilitate identification of needed improvements in palliative and EOL care that may improve the overall experiences for patients and families.

"Asking Is Never Bad, I Would Venture on That": Patients' Perspectives on Routine Pain Screening in VA Primary Care.

OBJECTIVE: Screening for pain in routine care is one of the efforts that the Veterans Health Administration has adopted in its national pain management strategy. We aimed to understand patients' perspectives and preferences about the experience of being screened for pain in primary care. DESIGN: Semistructured interviews captured patient perceptions and preferences of pain screening, assessment, and management. SUBJECTS: We completed interviews with 36 patients: 29 males and seven females ranging in age from 28 to 94 years from three geographically distinct VA health care systems. METHODS: We evaluated transcripts using constant comparison and identified emergent themes. RESULTS: Theme 1: Pain screening can "determine the tone of the examination"; Theme 2: Screening can initiate communication about pain; Theme 3: Screening can facilitate patient recall and reflection; Theme 4: Screening for pain may help identify under-reported psychological pain, mental distress, and suicidality; Theme 5: Patient recommendations about how to improve screening for pain. CONCLUSION: Our results indicate that patients perceive meaningful, positive impacts of routine pain screening that as yet have not been considered in the literature. Specifically, screening for pain may help capture mental health concerns that may otherwise not emerge.

Veteran Experiences Seeking Non-pharmacologic Approaches for Pain.

Introduction: Pain is a longstanding and growing concern among US military veterans. Although many individuals rely on medications, a growing body of literature supports the use of complementary non-pharmacologic approaches when treating pain. Our objective is to characterize veteran experiences with and barriers to accessing alternatives to medication (e.g., non-pharmacologic treatments or non-pharmacologic approaches) for pain in primary care. Materials and Methods: Data for this qualitative analysis were collected as part of the Effective Screening for Pain (ESP) study (2012-2017), a national randomized controlled trial of pain screening and assessment methods. This study was approved by the Veterans Affairs (VA) Central IRB and veteran participants signed written informed consent. We recruited a convenience sample of US military veterans in four primary care clinics and conducted semi-structured interviews (25-65 min) elucidating veteran experiences with assessment and management of pain in VA Healthcare Systems. We completed interviews with 36 veterans, including 7 females and 29 males, from three VA health care systems. They ranged in age from 28 to 94 yr and had pain intensity ratings ranging from 0 to 9 on the "pain now" numeric rating scale at the time of the interviews. We analyzed interview transcripts using constant comparison and produced mutually agreed upon themes. Results: Veteran experiences with and barriers to accessing complementary non-pharmacologic approaches for pain clustered into five main themes: communication with provider about complementary approaches ("one of the best things the VA has ever given me was pain education and it was through my occupational therapist"), care coordination ("I have friends that go to small clinic in [area A] and I still see them down in [facility in area B] and they're going through headaches upon headaches in trying to get their information to their primary care docs"), veteran expectations about pain experience ("I think as a society we have shifted the focus to if this doctor doesn't relieve me of my pain I will find someone who does"), veteran knowledge and beliefs about various complementary non-pharmacologic approaches ("how many people know that tai chi will help with pain?… Probably none. I saw them doing tai chi down here at the VA clinic and the only reason I knew about it was because I saw it being done"), and access ("the only physical therapy I ever did… it helped…but it was a two-and-a-half-hour drive to get there three times a week… I can't do this"). Specific access barriers included local availability, time, distance, scheduling flexibility, enrollment, and reimbursement. Conclusion: The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.

Barriers to Using Nonpharmacologic Approaches and Reducing Opioid Use in Primary Care.

BACKGROUND: Opioid prescribing for chronic pain, including the potential for over-reliance and misuse, is a public health concern. OBJECTIVE: In the context of Veterans Administration (VA) primary care team-based pain management, we aimed to understand providers' perceptions of barriers to reducing opioid use and improving the use of nonpharmacologic pain management therapies (NPTs) for chronic pain. DESIGN: A semistructured interview elucidated provider experiences with assessing and managing pain. Emergent themes were mapped to known dimensions of VA primary care access. SUBJECTS: Informants included 60 primary care providers, registered nurses, licensed practical nurses, clerks, psychologists, and social workers at two VA Medical Centers. METHODS: Nine multidisciplinary focus groups. RESULTS: Provider perceptions of barriers to reducing opioids and improving use of NPTs for patients with chronic pain clustered around availability and access. Barriers to NPT access included the following subthemes: geographical (patient distance from service), financial (out-of-pocket cost to patient), temporal (treatment time delays), cultural (belief that NPTs increased provider workload, perception of insufficient training on NPTs, perceptions of patient resistance to change, confrontation avoidance, and insufficient leadership support), and digital (measure used for pain assessment, older patients hesitant to use technology, providers overwhelmed by information). CONCLUSIONS: Decreasing reliance on opioids for chronic pain requires a commitment to local availability and provider-facing strategies that increase efficacy in prescribing NPTs. Policies and interventions for decreasing utilization of opioids and increasing use of NPTs should comprehensively consider access barriers.

Patient perspectives on an opioid overdose education and naloxone distribution program in the U.S. Department of Veterans Affairs.

BACKGROUND: In an effort to prevent opioid overdose mortality among Veterans, Department of Veterans Affairs (VA) facilities began implementing opioid overdose education and naloxone distribution (OEND) in 2013 and a national program began in 2014. VA is the first national health care system to implement OEND. The goal of this study is to examine patient perceptions of OEND training and naloxone kits. METHODS: Four focus groups were conducted between December 2014 and February 2015 with 21 patients trained in OEND. Participants were recruited from a VA residential facility in California with a substance use disorder treatment program (mandatory OEND training) and a homeless program (optional OEND training). Data were analyzed using matrices and open and closed coding approaches to identify participants' perspectives on OEND training including benefits, concerns, differing opinions, and suggestions for improvement. RESULTS: Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement. CONCLUSIONS: OEND training was generally well received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives. Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other health care settings. Training is critical to maximizing the potential for OEND to save lives, and this study includes specific suggestions for improving the effectiveness and acceptability of training.