Poster Number-17 - Determining the Representativeness of Participants in a Whole Health Interdisciplinary Chronic Pain Program (PREVAIL) in a VA Medical Center: Who Did We Reach?

Determining the Representativeness of Participants in a Whole Health Interdisciplinary Chronic Pain Program (PREVAIL) in a VA Medical Center: Who Did We Reach?

Purpose:

Chronic pain is a leading cause of disability and healthcare costs worldwide; however, chronic pain is known to be more prevalent in the Veteran and Appalachian populations. Interdisciplinary teams (IDTs) are the gold standard treatment, but there is significant variability in the delivery of services by IDTs. Most IDTs either involve several weeks of programming (Interdisciplinary Pain Rehabilitation Program; IPRP) or use a consultative model that lacks follow-up with patients. A model program that reduces patient and healthcare system burden, but still accounts for the interplay of biological, psychological, and social factors is needed. The Salem VA Medical Center developed an innovative approach to IDT, called PREVAIL, in which Veterans initially meet with a team of five providers of varying disciplines (interventional pain, psychology, pharmacy, physical therapy, and nutrition) to develop a patient-centered treatment plan based on the biopsychosocial model with a heavy emphasis on active self-management strategies and the Whole Health framework. Following the initial meeting with the IDT, Veterans engage in 6 months of follow-up calls, agreed upon pain treatments (psychotherapy, physical therapy, kinesiotherapy, acupuncture, chiropractic care, injections, etc.), and patient-driven goals for use of self-management strategies. Veterans are re-evaluated after 6 months by the IDT team to discuss progress. Seeing that the prescription of opioids is more prevalent in rural areas and the PREVAIL IDT program emphasizes nonpharmacological and self-management strategies for pain, Veterans’ willingness to participate in this type of programming needs to be explored. The purpose of this work is to understand the characteristics of Veterans who were willing to engage in this new type of intervention.

Methods:

This was a retrospective study which involved reviewing electronic medical records for Veterans who participated in PREVAIL IDT during the first six months of pilot testing, in addition to reviewing clinically ascertained self-report data which are administered as part of the PREVAIL IDT process. Any Veteran with chronic pain who attended an initial individual IDT appointment at the Salem VA Medical Center was eligible for chart review. Self-report measures were collected using 2 methods: paper-pencil (PROMIS-29, Pain Catastrophizing Scale (PCS)) and electronically (sent to Veterans via text and email using the Behavioral Health Touch Lab system within VHA; PEG, Pain Stages of Change Questionnaire (PSOCQ)). The following variables were obtained from the electronic medical record (EMR) and explored using descriptive statistics: gender, age, prescribed opioid use, and frequency of emergency service utilization due to pain in the year prior to IDT evaluation.  General comparisons were made between proportions of various characteristics in the chronic pain and Veteran populations, particularly those participating in IPRP’s, with those in the PREVAIL program.

Results:

The study sample comprised of 34 Veterans with chronic pain who attended an initial individual IDT appointment within the first 5 months of the program’s inception (i.e., 01/05/2022-06/01/2022). Paper-pencil measures were completed by 50% of Veterans (PROMIS-29 and PCS; N=17) whereas 76.4% completed the electronically administered measures (PSOCQ, PEG; N= 27). The mean age of participants was 56.85 years (SD = 12.35) and the majority of participants were male (79.4%; N=27). Data from the EMR in all Veterans (N=34) showed that 79.4% were not prescribed an opioid pain medication at the time of their initial IDT appointment, but most (58.8%) had sought emergency services for pain at least once in the year prior to their initial IDT appointment (range = 0-12 pain-related emergency department visits). Participants’ ratings tended to suggest severe intensity of pain that had a significant impact on their lives (PEG median= 7, SD = 1.73, range= 2-10; PROMIS-29 Pain Intensity T-score median= 6, SD= 1.46; PROMIS-29 Pain Interference T-score median= 66.60, SD = 5.01) in addition to moderate difficulties with physical functioning (PROMIS-29 Physical Functioning T-score median= 35.60; SD = 2.67). Participants’ average quality of life was wide ranging (ACPA QOL Scale; range= 1-9), though the average score of 4 suggests Veterans were able to complete simple chores around the home and participate in minimal activities outside the home two days per week. Regarding mental health participants, on average, reported moderate anxiety (PROMIS-29 Anxiety T-score median= 63.40; SD = 9.60) and depression (PROMIS-29 T-score median= 60.50; SD = 10.23). Nearly half of respondents (46%) scored above the clinical cutoff for significant pain catastrophizing (PCS median= 26.00, SD = 12.56). Results indicated Veterans were in a wide range of stages of change, indicating variable levels of motivation to engage in self-management of pain (PSOCQ; Precontemplation= 23.5%, Contemplation= 14.7%, Action= 26.5%, Maintenance= 11.8%).

Conclusion:

Veterans reached by the initial PREVAIL IDT evaluation tended to be similar to those who engaged in civilian IPRP’s in their age, severe pain, high pain interference, ER visits, moderate pain catastrophizing, and wide-ranging readiness to engagement in pain self-management. However, participants in PREVAIL tended to have more significant mental health symptoms, which is consistent with the literature on the prevalence of mental health concerns in Veterans with chronic pain. Surprisingly few PREVAIL participants were being prescribed opioid medication when seen by the IDT and most were at least contemplating or working towards pain self-management. Given that opioids tend to be prescribed more frequently in rural populations, it is possible that PREVAIL attracts Veterans who are more interested in a nonpharmacological approach and that further outreach may be needed for Veterans currently being prescribed opioids. Since patient-centered approaches are often associated with higher motivation to engage in treatment and higher motivation leads to better IDT outcomes, understanding the impact of PREVAIL on motivation to self-manage pain is essential. Additionally, administration of self-report measures via the BHL system may be a more effective method in the future since this method resulted in a higher completion rate (26%) than paper-pencil method.  

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