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Using Technology to Enhance Access to Evidence-Based Pain Care

Painful musculoskeletal and connective tissue disorders are highly prevalent among VA patients and are the most common diagnoses among Operations Enduring Freedom, Iraqi Freedom, and New Dawn Veterans. VA data suggest an annualized increase in the prevalence of low back pain, one of the most common musculoskeletal diagnoses, of 5% per year due to factors such as an aging population and increasing prevalence of obesity. Pain among Veterans is associated with serious negative outcomes, including emotional distress, diminished physical functioning, increased health care utilization, and more frequent engagement in health-risk behaviors (e.g., substance use).

In 2011, the Institute of Medicine (IOM) called for a cultural transformation to improve the quality of pain care with a recommendation for promoting and enabling pain self-management as a first step in pain treatment. Cognitive behavioral therapy (CBT) for chronic pain is a widely used self-management intervention that has been shown to reduce pain and associated disability and distress. Though effective, CBT requires that patients attend multiple in-person visits and that highly trained staff be available to provide care. For these reasons CBT is resource intensive, often inaccessible to Veterans, and delivered unevenly across patients and facilities. As the number of Veterans with chronic pain has increased, VA's capacity to provide the recommended evidence-based pain self-management support services to all Veterans who could benefit has been strained, with access to these services a significant challenge.

In an HSR&D-funded comparative effectiveness trial, investigators from HSR&D's Pain Research, Informatics, and Multi-morbidities and Education (PRIME) Center in West Haven, CT, and HSR&D's Center for Clinical Management Research (CCMR) in Ann Arbor, MI, found that CBT delivered via an automated Interactive Voice Response (IVR) system called Cooperative Pain Education and Self-management (COPES) leads to patient-centered outcomes that are no less effective than standard VA approaches in which CBT is delivered in-person by a therapist. Because COPES uses scalable, automated messaging to deliver in-home self-management support, it has the potential to reach the large number of Veterans with chronic pain who have limited access to specialty pain management services.

A project designed to evaluate strategies for implementing COPES more broadly is part of the recently funded Improving Pain-Related Outcomes for Veterans (IMPROVE) QUERI program. QUERI investigators will conduct a multi-site trial to evaluate the effectiveness of a facilitation-based approach on Veteran enrollment in COPES. They also will specifically target Veterans receiving their primary care in community-based outpatient clinics, who often have limited access to specialty pain management services. This study will:

• Identify overall and site-specific barriers and facilitators that influence the implementation of COPES;
• Identify patient-reported barriers to engaging in pain self-management interventions;
• Identify provider-reported barriers to incorporating pain self-management interventions into care; and
• Collaborate with partners in VA's National Pain Management Program Office and Primary Care Operations to use actionable information from this study to inform care and policy decisions.

For more information about this study, please contact Alicia Heapy, PhD at alicia.heapy@va.gov, Principal Investigator, QUERI IMPROVE Program, or John Piette, PhD at john.piette@va.gov.