Benchmark findings from a veteran electronic patient-reported outcomes evaluation from a chronic pain management telehealth program.

BACKGROUND: Chronic pain is a leading cause of disability and negatively impacts biological/physical, psychological, and social aspects of life resulting in significant pain interference or disability. This project was part of a longitudinal mixed-methods implementation evaluation of the TelePain-Empower Veterans Program (EVP), a non-pharmacological chronic pain intervention. The purpose of this quality management project was to examine electronic patient-reported outcome measures (ePROs) including primary pain-related (intensity, interference, catastrophizing, kinesiophobia) and secondary outcomes (physical, psychological, acceptance, social) to determine TelePain-EVP effectiveness. Secondary purpose was to examine dosing effects to better understand potential dose relationships between EVP use and ePROs. METHODS: Standardized ePRO measures were examined at week 1 (baseline), week 10 (post-EVP), and week 26 (follow-up). Qualtrics, a cloud-based platform was used to collect ePRO data at each time point. Veterans that completed at-least one survey at any specified time point were categorized as responders (n = 221). Linear-mixed models (LMMs) were fit to assess changes for each primary and secondary ePRO. RESULTS: Participants ranged from 24 to 81 years old; veterans were typically male (65.16%), black or African American (76.47%), married or partnered (41.63%), attended at-least some college or vocational school (67.87%), and reported low back as their primary pain location (29.41%). There was a significant decrease in pain catastrophizing from baseline to post-TelePain-EVP (p < .001). However, pain catastrophizing improvement from baseline was not present at week 26 (p = .116). Pain interference also decreased from baseline to post-treatment (p = .05), but this improvement did not exceed the adjusted significance threshold. Additional pre-post improvements were also observed for certain secondary ePROs: psychological (anxiety, depression), acceptance (activities engagement). Only the activities engagement effect remained 26 weeks from baseline. Mixed results were observed for EVP dose across primary and secondary outcomes. CONCLUSIONS: Evidence from this evaluation indicate that TelePain-EVP has positive outcomes for certain pain (catastrophizing), psychological (anxiety, depression), and acceptance (activities engagement) for veterans with chronic pain. More TelePain related studies and enterprise-wide evaluations are needed along with comparative and cost effectiveness methods to determine patient benefits and the economic value gained of treatment options such as TelePain-EVP.

Qualitative Evaluation Informs the Implementation of a Telehealth Program to Manage Chronic Pain.

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans.

BACKGROUND: Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management. OBJECTIVES: The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation. METHODS: A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO. RESULTS: Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures. DISCUSSION: Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

Evaluation of a non-pharmacological interdisciplinary pain rehabilitation and functional restoration program for chronic pain in veterans.

OBJECTIVE: To conduct a quality improvement evaluation of the Empower Veterans Program (EVP), an interdisciplinary pain rehabilitation/functional restoration program option for functional restoration for high-impact chronic pain, offered in a large metro-area Veterans Health Administration (VHA) system. DATA SOURCES: VHA Corporate Data Warehouse electronic medical record data for patients treated by EVP between 2015 and 2019. EVALUATION DESIGN: This retrospective design first compared EVP patients considered engaged or not engaged in completing treatment in terms of demographic characteristics and post-treatment changes in clinical measures related to opioid use and mental health. We then compared mortality risk between matched groups of treated and untreated patients with chronic pain and concurrent opioid prescriptions using propensity score matching and Cox proportional hazards methods. "Treated" in the matched groups was defined as any level of EVP participation (i.e., both engaged and not engaged). DATA COLLECTION/EXTRACTION METHODS: We first identified 1053 EVP patients with 1 year of pre-and post-treatment follow-time and determined their engagement level. From those with chronic pain and prescription opioids, we matched 237 EVP patients to 375 untreated patients. PRINCIPAL FINDINGS: Engaged patients (57.4% of treated patients), were somewhat older than the non-engaged (mean age 57.1 vs. 53.7, Cohen's D = 0.30), and achieved lower mean PHQ9 depression scores in the post-treatment year (9.2 vs. 10.6, Cohen's D = 0.20). Participation in EVP was associated with a 65% lower mortality risk among Veterans with chronic pain and opioid use when compared to the untreated patients: (HR: 0.35, 95% CI: 0.17, 0.75). CONCLUSIONS: EVP was associated with a large reduction in mortality risk for Veterans with both chronic pain and opioid use. This result could inform the decision process in a VA station or region when considering providing or expanding access to an interdisciplinary rehabilitation/functional restoration program for chronic pain.

Noninfectious disease among the Bhutanese refugee population at a United States urban clinic.

A large number of Bhutanese are currently being resettled to the United States. A high prevalence of noninfectious diseases has been noted in some refugee groups, but data on the Bhutanese refugee population are lacking. A retrospective, chart review study was conducted to determine proportion of noninfectious disease among ethnically Nepali Bhutanese refugees (n = 66) seen at the Grady Refugee Clinic (GRC). GRC disease proportions included the following: 52 % of the patients were overweight/obese (n = 34), 23 % were hypertensive (n = 15), 12 % had vitamin B(12) deficiency (n = 8), 15 % had depression (n = 10), and 14 % had diabetes (n = 9). Nine (90 %) patients with depression had chronic disease compared to 30 (54 %) of the patients without depression. The study found a substantial burden of chronic disease, micronutrient deficiency, and depression in the GRC. Further research is needed to accurately describe the disease burden in refugee populations and to evaluate pre-resettlement disease prevention strategies to provide a framework for future public health interventions.