Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: results from the study of the effectiveness of a collaborative approach to pain.

OBJECTIVE: We assessed primary care clinician-provided guideline-concordant care as documented in patients' medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team. METHODS: To assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (≥30% decrease in Roland-Morris Disability Questionnaire score). RESULTS: Rates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively). CONCLUSIONS: As measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.

VA healthcare costs of a collaborative intervention for chronic pain in primary care.

BACKGROUND: Chronic pain is costly to individuals and the healthcare system, and is often undertreated. Collaborative care models show promise for improving treatment of patients with chronic pain. The objectives of this article are to report the incremental benefit and incremental health services costs of a collaborative intervention for chronic pain from a veterans affairs (VA) healthcare perspective. METHODS: Data on VA treatment costs incurred by participants were obtained from the VA's Decision Support System for all utilization except certain intervention activities which were tracked in a separate database. Outcome data were from a cluster-randomized trial of a collaborative intervention for chronic pain among 401 primary care patients at a VA medical center. Intervention group participants received assessments and care management; stepped-care components were offered to patients requiring more specialized care. The main outcome measure was pain disability-free days (PDFDs), calculated from Roland-Morris Disability Questionnaire scores. RESULTS: Participants in the intervention group experienced an average of 16 additional PDFDs over the 12-month follow-up window as compared with usual care participants; this came at an adjusted incremental cost of $364 per PDFD for a typical participant. Important predictors of costs were baseline medical comorbidities, depression severity, and prior year's treatment costs. CONCLUSIONS: This collaborative intervention resulted in more pain disability-free days and was more expensive than usual care. Further research is necessary to identify if the intervention is more cost-effective for some patient subgroups and to learn whether pain improvements and higher costs persist after the intervention has ended.

Collaborative care for chronic pain in primary care: a cluster randomized trial.

CONTEXT: Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use. OBJECTIVE: To assess whether a collaborative intervention can improve chronic pain-related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008. INTERVENTION: Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care. MAIN OUTCOME MEASURES: Changes over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month). RESULTS: Intervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P = .004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P = .01). Among patients with baseline depression (PHQ-9 score > or = 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P = .003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9. CONCLUSION: The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00129480.

Rationale, design, and baseline findings from a randomized trial of collaborative care for chronic musculoskeletal pain in primary care.

OBJECTIVE: This article describes the rationale, design, and baseline findings from an ongoing study of collaborative care for chronic musculoskeletal pain and comorbid depression. DESIGN: Cluster randomized clinical trial. PARTICIPANTS AND SETTING: Forty-two clinicians and 401 patients from five Veterans Affairs primary care clinics. INTERVENTION: The intervention was based on the chronic care model, and included patient and provider activation and education, patient assessment, outcomes monitoring, and feedback to providers over 12 months. The intervention team consisted of a full-time psychologist care manager and a part-time physician internist. Approaches included goal setting emphasizing function, patient activation and educating about fear avoidance, and care management. OUTCOME MEASURES: Main outcomes are Roland-Morris Disability Questionnaire (RMDQ) score, depression severity (Patient Health Questionnaire-9), and pain severity (Chronic Pain Grade Severity subscale) at 6 and 12 months. BASELINE RESULTS: Fifteen percent of primary care patients mailed a study advertisement letter requested screening for the study. The mean age of enrolled patients was 62. Back and neck or joint pain diagnoses were present in 67% and 65% of patients, respectively. Mean pain duration was 15 years, and mean RMDQ score (range 0-24) was 14.7 (standard deviation = 4.4). Sixty-five percent of patients were receiving disability. Eighteen percent of patients met criteria for major depression, 17% for posttraumatic stress disorder, and 9% for alcohol misuse. Thirty-nine percent of patients felt strongly that experiencing pain was a sign of damage, and 60% reported strong avoidance of painful activities. CONCLUSIONS: These baseline data support the rationale to develop a multifaceted approach to treat chronic pain in primary care that includes detection and treatment of psychiatric comorbidity.

Veterans affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates.

OBJECTIVES: The primary objective of this study was to identify veterans affairs (VA) primary care clinicians' attitudes regarding chronic pain treatment. A secondary objective was to explore relationships between clinician and practice characteristics and an objective measure of opioid prescribing rates. DESIGN: Cross-sectional study of clinician survey and pharmacy data. PARTICIPANTS: Forty-five VA clinicians from five primary care clinics of one VA medical center. MEASURES: Survey of pain-related attitudes and behaviors, satisfaction with treatment resources, and job satisfaction; percentage of patients in clinicians' panels prescribed opioids (PCPO). RESULTS: Seventy-one percent of clinicians felt moderately or strongly confident in their ability to treat chronic pain, and 77% moderately or strongly agreed that skilled pain management is a high priority. However, 73% moderately or strongly agreed that patients with chronic pain are a major source of frustration and 38% reported moderate or greater dissatisfaction with their ability to provide optimal pain treatment. Fifty-two percent moderately or strongly agreed that their management is influenced by previous experiences with patients addicted to drugs. The mean PCPO was 16.5% (SD = 6.7). In bivariate comparisons, clinician panel size, job and resource satisfaction, and professional training were associated with opioid prescribing rates. CONCLUSION: High clinician confidence and interest in treating chronic pain concurrent with low satisfaction with ability to provide optimal treatment suggests a need for more system support. VA primary care clinicians are frequently influenced by fears of contributing to dependence or addiction. The relationships among panel size, job satisfaction, and opioid prescribing rates merit additional investigation.

Screening for posttraumatic stress disorder in VA primary care patients with depression symptoms.

BACKGROUND: Unrecognized posttraumatic stress disorder (PTSD) is common and may be an important factor in treatment-resistant depression. Brief screens for PTSD have not been evaluated for patients with depression. OBJECTIVE: The objective was to evaluate a 4-item screen for PTSD in patients with depression. DESIGN: Baseline data from a depression study were used to evaluate sensitivity, specificity, and likelihood ratios (LRs) using the PTSD checklist (PCL-17) as the reference standard. SUBJECTS: Subjects are 398 depressed patients seen in Veterans Affairs (VA) primary care clinics. MEASURES: The Patient Health Questionnaire (PHQ) for depression, PCL-17, and 4-item screen for PTSD were used. RESULTS: Patients had a mean PHQ score of 14.8 (SD 3.7). Using a conservative PCL-17 cut point "(>50)", the prevalence of PTSD was 37%. PCL-17 scores were strongly associated with PHQ scores (r = 0.59, P < 0.001). Among the 342 (86%) patients endorsing trauma, a score of 0 on the remaining 3 symptom items had a LR = 0.21, score of 1 a LR = .62, score of 2 a LR = 1.36, and score of 3 a LR = 4.38. CONCLUSIONS: Most depressed VA primary care patients report a history of trauma, and one third may have comorbid PTSD. Our 4-item screen has useful LRs for scores of 0 and 3. Modifying item rating options may improve screening characteristics.

Depression decision support in primary care: a cluster randomized trial.

BACKGROUND: Intensive collaborative interventions improve depression outcomes, but the benefit of less intensive interventions is not clear. OBJECTIVE: To determine whether decision support improves outcomes for patients with depression. DESIGN: Clinician-level, cluster randomized, controlled trial. SETTING: 5 primary care clinics of 1 Veterans Affairs medical center. PARTICIPANTS: 41 primary care clinicians, and 375 patients with depression (Patient Health Questionnaire [PHQ-9] depression scores of 10 to 25 or Hopkins Symptom Checklist-20 [SCL-20] scores > or = 1.0). MEASUREMENTS: The primary outcome was change in depression score (SCL-20) at 6 and 12 months. Secondary outcomes were health-related quality-of-life (36-item Short Form for Veterans [SF-36V] score), patient satisfaction, antidepressant use, and health care utilization. INTERVENTION: Clinicians received depression education and were randomly assigned to depression decision support or usual care. The depression decision support team, which consisted of a psychiatrist and nurse, provided 1 early patient educational contact and depression monitoring with feedback to clinicians over 12 months. RESULTS: Although SCL-20 depression scores improved in both groups, the intervention had no effect compared with usual care. The difference in slopes comparing intervention and control over 12 months was 0.20 (95% CI, -0.37 to 0.78; P = 0.49), which was neither clinically nor statistically significant. Changes in SF-36V scores also did not differ between groups. At 12 months, intervention patients reported greater satisfaction (P = 0.002) and were more likely to have had at least 1 mental health specialty appointment (41.1% vs. 27.2%; P = 0.025), to have received any antidepressant (79.3% vs. 69.3%; P = 0.041), and to have received antidepressants for 90 days or more (76.2% vs. 61.6%; P = 0.008). LIMITATIONS: Usual care clinicians received depression education and had on-site mental health support, which may have mitigated intervention effectiveness. CONCLUSIONS: Decision support improved processes of care but not depression outcomes. More intensive care management or specialty treatment may be needed to improve depression outcomes.

"Finding the Right FIT": Rural Patient Preferences for Fecal Immunochemical Test (FIT) Characteristics.

PURPOSE: Colorectal cancer (CRC) is the third leading cause of cancer death in the United States, yet 1 in 3 Americans have never been screened for CRC. Annual screening using fecal immunochemical tests (FITs) is often a preferred modality in populations experiencing CRC screening disparities. Although multiple studies evaluate the clinical effectiveness of FITs, few studies assess patient preferences toward kit characteristics. We conducted this community-led study to assess patient preferences for FIT characteristics and to use study findings in concert with clinical effectiveness data to inform regional FIT selection. METHODS: We collaborated with local health system leaders to identify FITs and recruit age eligible (50 to 75 years), English or Spanish speaking community members. Participants completed up to 6 FITs and associated questionnaires and were invited to participate in a follow-up focus group. We used a sequential explanatory mixed-methods design to assess participant preferences and rank FIT kits. First, we used quantitative data from user testing to measure acceptability, ease of completion, and specimen adequacy through a descriptive analysis of 1) fixed response questionnaire items on participant attitudes toward and experiences with FIT kits, and 2) a clinical assessment of adherence to directions regarding collection, packaging, and return of specimens. Second, we analyzed qualitative data from focus groups to refine FIT rankings and gain deeper insight into the pros and cons associated with each tested kit. FINDINGS: Seventy-six FITs were completed by 18 participants (Range, 3 to 6 kits per participant). Over half (56%, n = 10) of the participants were Hispanic and 50% were female (n = 9). Thirteen participants attended 1 of 3 focus groups. Participants preferred FITs that were single sample, used a probe and vial for sample collection, and had simple, large-font instructions with colorful pictures. Participants reported challenges using paper to catch samples, had difficulty labeling tests, and emphasized the importance of having care team members provide verbal instructions on test completion and follow-up support for patients with abnormal results. FIT rankings from most to least preferred were OC-Light, Hemosure iFOB Test, InSure FIT, QuickVue, OneStep+, and Hemoccult ICT. CONCLUSIONS: FIT characteristics influenced patient's perceptions of test acceptability and feasibility. Health system leaders, payers, and clinicians should select FITs that are both clinically effective and incorporate patient preferred test characteristics. Consideration of patient preferences may facilitate FIT return, especially in populations at higher risk for experiencing CRC screening disparities.

Collaborative care for pain results in both symptom improvement and sustained reduction of pain and depression.

OBJECTIVE: Traditional analytic approaches may oversimplify the mechanisms by which interventions effect change. Transition probability models can quantify both symptom improvement and sustained reduction in symptoms. We sought to quantify transition probabilities between higher and lower states for four outcome variables and to compare two treatment arms with respect to these transitions. METHOD: Secondary analysis of a year-long collaborative care intervention for chronic musculoskeletal pain in veterans. Forty-two clinicians were randomized to intervention or treatment as usual (TAU), with 401 patients nested within clinician. The outcome variables, pain intensity, pain interference, depression and disability scores were dichotomized (lower/higher). Probabilities of symptom improvement (transitioning from higher to lower) or sustained reduction (remaining lower) were compared between intervention and TAU groups at 0- to 3-, 3- to 6- and 6- to 12-month intervals. General estimating equations quantified the effect of the intervention on transitions. RESULTS: In adjusted models, the intervention group showed about 1.5 times greater odds of both symptom improvement and sustained reduction compared to TAU, for all the outcomes except disability. CONCLUSIONS: Despite no formal relapse prevention program, intervention patients were more likely than TAU patients to experience continued relief from depression and pain. Collaborative care interventions may provide benefits beyond just symptom reduction.

Measuring adherence to depression treatment guidelines in a VA primary care clinic.

The primary objectives of this pilot study were to develop a measure of adherence for depression practice guidelines and to assess the degree to which providers and patients adhere to guidelines in a VA primary care setting. The Depression Guideline Measure (DGM) is based on three national guidelines. The DGM was used to review medical records of 111 patients with Patient Health Questionnaire (PHQ) scores >or=10. Interrater reliability for 15 of 19 DGM checklist items was excellent (kappa > 0.75). There was a broad range of adherence to guideline criteria: only 13.5% of patients were contacted for follow-up within 2 weeks, while 100% of providers documented follow-up plans. Forty percent of patients saw mental health providers, and 63% were prescribed antidepressants. A secondary objective of the study was to explore the relationship between guideline adherence and changes in PHQ scores. Among 51 patients who completed follow-up PHQs, no associations were detected. The results suggest that the DGM shows promise as a reliable measure of guideline adherence and that guideline criteria are frequently not met in busy primary care clinics. More research is needed to determine the validity of the DGM and the impact of guideline adherence on depression outcomes.

Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item.

OBJECTIVE: To evaluate the psychometric properties of a single-item depression screen against validated scoring algorithms for the Patient Health Questionnaire (PHQ) and the utility of these algorithms in screening for depression and suicidality in a Department of Veterans Affairs (VA) primary care setting. STUDY DESIGN: Recruitment phase of a randomized trial. METHODS: A total of 1211 Portland VA patients with upcoming primary care clinic appointments were administered by telephone a single item assessing depressed mood over the past year and the PHQ. The PHQ-9 (9 items) encompasses DSM-IV criteria for major depression, the PHQ-8 (8 items) excludes the thoughts of death or suicide item, and the PHQ-2 (2 items) assesses depressed mood and anhedonia. Patients whose responses suggested potential suicidality were administered 2 additional items assessing suicidal ideation. Patients receiving mental health specialty care were excluded. RESULTS: Using the PHQ-9 algorithm for major depression as the reference standard, the VA single-item screen was specific (88%) but less sensitive (78%). A PHQ-2 score of > or =3 demonstrated similar specificity (91%) with high sensitivity (97%). For case finding, the PHQ-8 was similar to the PHQ-9. Approximately 20% of patients screened positive for moderate depression, 7% reported thoughts of death or suicide, 2% reported thoughts of harming themselves, and 1% had specific plans. CONCLUSIONS: The PHQ-2 offers brevity and better psychometric properties for depression screening than the single-item screen. The PHQ-9 item assessing thoughts of death or suicide does not improve depression case finding; however, one third of patients endorsing this item reported recent active suicidal ideation.

Mental health utilization of new-to-care Iraq and Afghanistan Veterans following suicidal ideation assessment.

We evaluated the impact of brief structured suicidal ideation (SI) assessments on mental health care among new-to-care Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans. National datasets provided military, demographic, and clinical information. For all new-to-care OEF/OIF veterans administered depression screens (PHQ-2: Patient Health Questionnaire-2) and structured SI assessments in primary care or ambulatory mental health settings of three Veterans Affairs (VA) Medical Centers between April 2008 and September 2009 (N=465), generalized estimating equations were used to examine associations between SI and number of subsequent-year specialty mental health visits and antidepressant prescriptions. Approximately one-third of the veterans reported SI. In multivariate models, PTSD and anxiety diagnoses, severe depression symptoms, being married, and SI assessment by a mental health clinician were associated with more mental health visits in the subsequent year. Depression, PTSD, and anxiety diagnoses, and SI assessment by a mental health clinician were associated with receiving antidepressants. Presence of SI did not significantly affect subsequent year mental health utilization when adjusting for diagnostic and clinician variables, but inaugural visits involving mental health clinicians were consistently associated with subsequent mental health care.

Primary care clinician responses to positive suicidal ideation risk assessments in veterans of Iraq and Afghanistan.

OBJECTIVE: To examine primary care clinician actions following positive suicide risk assessments administered to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. METHODS: We identified OEF/OIF veterans with positive templated suicide risk assessments administered in primary care settings of three Veterans Affairs (VA) Medical Centers. National VA datasets and manual record review were used to identify and code clinician discussions and actions following positive assessments. Bivariate analyses were used to examine relationships between patient characteristics and discussions of firearms access and alcohol/drug use. RESULTS: Primary care clinicians documented awareness of suicide risk assessment results for 157 of 199 (79%) patients with positive assessments. Most patients were assessed for mental health conditions and referred for mental health follow-up. Clinicians documented discussions about firearms access for only 15% of patients. Among patients whose clinicians assessed for substance abuse, 34% received recommendations to reduce alcohol or drug use. Depression diagnoses and suicidal ideation/behavior severity were significantly associated with firearms access discussions, while patient sex, military service branch, and substance abuse diagnoses were significantly associated with recommendations to reduce substance use. CONCLUSION: Greater efforts are needed to understand barriers to clinicians' assessing, documenting and counseling once suicidal ideation is detected, and to develop training programs and systems changes to address these barriers.

Prevalence and correlates of suicidal ideation among Operation Enduring Freedom and Operation Iraqi Freedom veterans.

BACKGROUND: We sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans following the Department of Veterans Affairs' (VA) 2007 implementation of required brief SI assessments for veterans who screen positive for depression and post-traumatic stress disorder. METHODS: We retrospectively identified OEF/OIF veterans screened for depression using the Patient Health Questionnaire (PHQ-2) between April 2008 and September 2009 at three geographically-distinct VA Medical Centers' primary care or mental health clinics. Veteran responses to a two-item risk assessment tool (VA Pocket Card) or PHQ-9 9th item, administered following a positive depression screen (PHQ-2≥3), were determined using manual chart review. Generalized estimating equations were used to calculate adjusted odds ratios for demographic and clinical correlates of positive SI assessments. RESULTS: Of 1340 OEF/OIF veterans with positive depression screens, 32.4% reported SI. In multivariate models, odds of SI were lower for non-Hispanic white veterans (AOR=0.68) and greater for those with PHQ-2≥5 (AOR=1.87), depression (AOR=1.45), bipolar disorder/schizophrenia (AOR=2.84), and 2 or ≥3 diagnoses (AORs=1.59 and 2.49, respectively). LIMITATIONS: Study findings may not be generalizable to non-veteran patient populations and the study does not address the reliability and validity of tools employed for brief suicidal ideation assessment. CONCLUSIONS: SI is common among OEF/OIF veterans who receive VA care, perhaps more so among non-white veterans. Targeting veterans with higher PHQ-2 scores for SI assessment should be considered to reduce patient and administrative burden.

Brief assessment for suicidal ideation in OEF/OIF veterans with positive depression screens.

OBJECTIVES: We describe processes, rates, and patient and system correlates of brief structured assessments (BSAs) for suicidal ideation among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with positive depression screens. METHODS: Electronic Veterans Affairs (VA) medical record and Department of Defense data were used to identify individual-level and BSA-process variables for 1662 OEF/OIF veterans at three VA Medical Centers. RESULTS: Overall, 1349/1662 (81%) veterans received BSAs for suicidal ideation within 1 month of depression screening; 94% of BSAs were conducted within 1 day. Stratified analyses revealed significant intersite differences in veteran demographics, instruments used, clinical setting and staff performing assessments, and correlates of assessment completion. At two sites, men were more likely to be assessed than women [odds ratio (OR)=2.15 (95% confidence interval {CI}=1.06-4.38) and 3.14 (CI=1.27-7.76)]. In a combined model adjusted for intrasite correlation, assessment was less likely during months 8-12 and 13-18 of the study period [OR=0.39 (CI=0.28-0.54) and OR=0.48 (95% CI=0.35-0.68), respectively] and more likely to occur among veterans receiving depression or posttraumatic stress disorder diagnoses on the day of depression screening [OR=1.83 (CI=1.36-2.46) and OR=1.50 (CI=1.13-1.98), respectively]. CONCLUSIONS: Most veterans with positive depression screens receive timely BSAs for suicidal ideation. Processes used for brief assessment for suicidal ideation vary substantially across VA settings.

Complementary and alternative medicine use among veterans with chronic noncancer pain.

We describe prior use and willingness to try complementary and alternative medicine (CAM) among 401 veterans experiencing chronic noncancer pain and explore differences between CAM users and nonusers. Participants in a randomized controlled trial of a collaborative intervention for chronic pain from five Department of Veterans Affairs (VA) primary care clinics self-reported prior use and willingness to try chiropractic care, massage therapy, herbal medicines, and acupuncture. Prior CAM users were compared with nonusers on demographic characteristics, pain-related clinical characteristics, disease burden, and treatment satisfaction. A majority of veterans ( n = 327, 82%) reported prior use of at least one CAM modality, and nearly all (n = 399, 99%) were willing to try CAM treatment for pain. Chiropractic care was the least preferred option, whereas massage therapy was the most preferred (75% and 96%, respectively). CAM users were less likely to have service-connection disabilities (54% vs 68%; chi square = 4.64, p = 0.03) and reported having spent a larger percentage of their lives in pain (26% vs 20%; Z = 1.40, p = 0.04) than nonusers. We detected few differences between veterans who had tried CAM and those who had not, suggesting that CAM may have broad appeal among veterans with chronic pain. Implications for VA policy and practice and for clinicians treating veterans with chronic pain are discussed.

Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain.

UNLABELLED: The goal of this study was to examine relationships between substance use disorder (SUD) history and 12-month outcomes among primary care patients with chronic noncancer pain (CNCP). Patients were enrolled in a randomized trial of collaborative care intervention (CCI) versus treatment as usual (TAU) to improve pain-related physical and emotional function. At baseline, 72 of 362 patients (20.0%) had a history of SUD. Compared to CNCP patients without SUD, those with comorbid SUD had poorer pain-related function and were more likely to meet criteria for current major depression and posttraumatic stress disorder (all P values <.05). Logistic regression analyses were conducted to examine whether SUD status was associated with clinically significant change over 12 months in pain-related function (30% reduction in Roland Morris Disability Questionnaire Score). The overall model was not significant in the CCI group. However, within the TAU group, participants with a SUD history were significantly less likely to show improvements in pain-related function (OR = .30, 95% CI = .11-.82). CNCP patients with comorbid SUD reported greater functional impairment at baseline. Patients with SUD who received usual care were 70% less likely to have clinically significant improvements in pain-related function 12 months postbaseline, and SUD status did not impede improvement for the CCI group. PERSPECTIVE: Chronic noncancer pain patients with a history of a substance use disorder (SUD) report poorer pain-related functioning and are less likely to experience clinically significant improvements from usual pain treatment. Providers should assess for SUD status and provide more intensive interventions for these patients.

Depression treatment preferences of VA primary care patients.

The authors identified veterans' depression treatment preferences and explored relationships between preferences, process of care, and clinical outcomes. Patients entering a collaborative depression intervention trial in primary care completed an assessment of treatment preferences. Medical record review was used to identify treatments offered and received over a 12-month period. Of 314 patients, 32% preferred antidepressants; 19%, individual counseling; 18%, anti-depressants plus counseling; 7%, group counseling; and 25%, "watchful waiting." Although the treatment that was offered was associated with treatment preferences, being offered preferred treatment was not associated with receiving treatment or with changes in depression severity or satisfaction over time.

Measuring depression and pain with home health monitors.

The objective of this pilot study was to test the feasibility of using home health monitors to administer standardized measures for depression and pain in a Veterans Affairs (VA) patient population. Five patients were recruited from a larger study of collaborative depression care, and were asked to use Viterion 100 Telehealth monitors to transmit depression (Patient Health Questionnaire-9) and pain severity (SF36-V bodily pain items) scores on a weekly basis for 24 weeks. Information was received and reviewed by a nurse care manager, who recommended treatment changes as appropriate. The care manager occasionally followed up reports of changes in symptom severity with phone calls; in one case, she called to inquire why a patient was not submitting data. Overall, four patients were able to use the monitors successfully and frequently. Patient satisfaction was high: 5 of 5 reported that they would use monitors again, and 3 of 5 preferred monitors to phone or mail for completing questionnaires. Patients expressed no concerns about privacy. The data allowed tracking of the longitudinal interrelationship between depression and pain severity. However, the monitors were limited in their ability to display questionnaire items, and the system could neither directly compute measure scores nor transfer data to patient medical records. These results suggest that with modifications, home health monitoring shows promise for monitoring symptom severity for a variety of medical and mental health conditions, for either clinical or research purposes.

Psychiatry resident graduate comfort with general medical issues: impact of an integrated psychiatry-primary medical care training track.

OBJECTIVE: To determine if a psychiatry-primary medical care (PPMC) training track impacts comfort and behaviors related to addressing general medical issues after residency. METHOD: Thirty five psychiatry resident graduates completed mailed surveys; nine of them had completed the PPMC track. RESULTS: Compared to non-PPMC participants, PPMC participants felt better prepared to address medical issues and tended to perform more consultations and feel more comfortable referring patients to general medical providers. They were not more likely to perform routine health screenings. CONCLUSION: Integrated training tracks may impact resident preparedness and career choice but may be insufficient to influence practice behaviors related to delivering general medical care.