QUERI – Quality Enhancement Research Initiative

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QUERI E-news: Enhancing Veteran Care through Implementation, Technology, and User-Centered Design

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Collaborative Care Intervention to Improve Pain Management

The Primary Care-Integrated Pain Support (PIPS) project studies the implementation of a pharmacist-led pain care program designed to decrease the number of Veterans receiving high-dose opioid and combination opioid-benzodiazepine therapy, while increasing engagement with non-pharmacologic pain treatment. The effectiveness of the clinical intervention and implementation strategy – implementation facilitation – are being evaluated simultaneously by investigators with QUERI’s Improving Pain-Related Outcomes for Veterans (IMPROVE) national program. Implementation is underway at three sites: VA Eastern Colorado Health Care System, Central Arkansas Veterans Healthcare System, and the Tennessee Valley Healthcare System.

IMPROVE QUERI investigators are working to identify factors that influence the progress and effectiveness of implementation efforts. In addition to diagnosing factors critical to implementation success, they will tailor an implementation strategy around those factors to effectively enable improvements in opioid prescribing related to PIPS in clinical practice. Investigators also will identify factors related to evidence, context, and facilitation at study sites. Interviews with stakeholders will provide an even more in-depth understanding of these factors.

Findings

IMPROVE QUERI investigators have published a pre-implementation mixed methods formative evaluation that revealed prominent themes.1 For example, stakeholders identified system-level barriers such as tension among various pain management-related providers illustrated by the following quote, “You know, we have a strong-minded leader of our chronic pain management clinic. We have a strong leader leading our primary care program. And getting them on the same page and getting them focused on doing what they say they're going to do have been very problematic.” Others described patient-related barriers to engagement in programs focused on tapering. “I guess the biggest challenge patients feel is that they feel alone,” remarked one interviewee. Facilitating factors of PIPS, such as the importance of the clinical pharmacist role were also identified. One participant noted, “So, we utilize clinical pharmacists as part of the PACT model … and it's been a very positive experience. So, each clinic has a clinical pharmacist, and they have fairly designated roles, particularly chronic disease management so they work with protocols and diabetes management; hypertension, thyroid, smoking cessation, and they are allowed to adjust medications as part of that management. So, I think… we've had a really good experience. They work very well embedded in the teams so they're fairly integrated with the primary care team which has been very helpful too.”

All told, the factors identified by providers provide insight into factors that could influence the implementation of the clinical intervention.

Impact

The results of these research activities will help VA Primary Care – the service line responsible for most of chronic pain management both in and outside VA – to align pain treatment with evidence-based, consensus recommendations with respect to opioid safety and multimodal pain care, thereby reducing risks of serious opioid-related consequences while preserving patients’ quality of life and functional status. These results also can be used by VISN leadership to enact the mandates of the Opioid Safety Initiative (OSI) and lay the foundation for a broader dissemination and implementation trial focused on spread and sustainment.

For more information, please contact Leonore Okwara, MPH, at Leonore.Okwara@va.gov .

Reference

Becker W, Mattocks K, Frank J, et al. Mixed methods formative evaluation of a collaborative care program to decrease risky opioid prescribing and increase non-pharmacologic approaches to pain management. Addictive Behaviors. March 8, 2018; Epub ahead of print.

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