Pain Medicine 2015; 16: 1090–1100 Wiley Periodicals, Inc.
PRIMARY CARE & HEALTH SERVICES SECTION Original Research Article Evaluation of a Telementoring Intervention for Pain Management in the Veterans Health Administration
*VA Eastern Colorado Health Care System, Denver, Colorado; †Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado; ‡ Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; §Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; ¶VA Puget Sound Health Care System, Seattle, Washington; **Yale University School of Medicine, New Haven, Connecticut; ††VA Connecticut Healthcare System, West Haven, Connecticut; ‡‡Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; §§Office of Specialty Care, Veterans Health Administration, Washington, DC, USA Reprint Requests to: Joseph W. Frank, MD, MPH, Ambulatory Care, VA Eastern Colorado Health Care System, 1055 Clermont Street, Denver, CO 80220, USA. Tel: 317-509-0071; Fax: 303-724-2270; E-mail: [email protected]
Authorship information: Concept and design (all authors); data collection (EPC, JTS); data analysis (EPC); data interpretation (all authors); drafting of the manuscript (JWF); critical revision of the manuscript for important intellectual content (all authors).
Services, Patient Care Services, Veterans Health Administration, Washington DC. Dr. Frank was supported by the VA Eastern Colorado Health Care System and the University of Colorado School of Medicine. Drs. Ho and Au were supported by the Denver-Seattle Center of Innovation for VeteranCentered and Value-Driven Care (DiSCoVVR). Drs. Kerns and Moore were supported by the Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center of Innovation at the VA Connecticut Healthcare System, West Haven, CT. Role of Funders/Sponsors: This project was conducted as part of VHA health care operations in compliance with VHA Handbook 1058.05. The project team had full responsibility for the design and conduct of the operational evaluation activities, as focused on the implementation of transformational initiatives of interest to the VA Office of Specialty Care Services (SCS)\Specialty Care Transformation (OSCT); collection, management, analysis, and interpretation of the data; and preparation of the manuscript. One of the co-authors of the manuscript is employed by OSCT. Previous presentations: An abstract of this study was presented at the Mountain West Regional Meeting of the Society of General Internal Medicine in Denver, CO on October 10, 2014. Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs.
Abstract Conflict of interest: The authors report no conflicts of interest, including relevant financial interests, activities, relationships, and affiliations. Sources of funding: This work was supported by T-21 funds and the Office of Specialty Care Services/Specialty Care Transformation, Office of Specialty Care 1090
Objective. Half of all Veterans experience chronic pain yet many face geographical barriers to specialty pain care. In 2011, the Veterans Health Administration (VHA) launched the Specialty Care Access Network-ECHO (SCAN-ECHO), which uses telehealth technology to provide primary care providers
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Joseph W. Frank, MD, MPH,*,† Evan P. Carey, MS,* Katherine M. Fagan, MPH,* David C. Aron, MD, MS,‡,§ Jeff Todd-Stenberg, BA,¶ Brent A. Moore, PhD,**,†† Robert D. Kerns, PhD,**,†† David H. Au, MD, MS,¶ P. Michael Ho, MD, PhD,*,‡‡ and Susan R. Kirsh, MD, MPH‡,§,§§
VA SCAN-ECHO for Pain Management with case-based specialist consultation and pain management education. Our objective was to evaluate the pilot SCAN-ECHO pain management program (SCAN-ECHO-PM). Design and Setting. This was a longitudinal observational evaluation of SCAN-ECHO-PM in seven regional VHA healthcare networks.
Results. Primary care providers (N 5 159) who presented one or more SCAN-ECHO-PM sessions had patient panels of 22,454 patients with chronic noncancer pain (CNCP). Provider consultation to SCANECHO-PM was associated with utilization of physical medicine [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.05–1.14] but not mental health (HR 0.99, 95% CI 0.93–1.05), substance use disorder (HR 0.93, 95% CI 0.84–1.03) or specialty pain clinics (HR 1.01, 95% CI 0.94–1.08). SCAN-ECHO-PM consultation was associated with initiation of an antidepressant (HR 1.09, 95% CI 1.02–1.15) or anticonvulsant medication (HR 1.13, 95% CI 1.06–1.19) but not an opioid analgesic (HR 1.05, 0.99–1.10). Conclusions. SCAN-ECHO-PM was associated with increased utilization of physical medicine services and initiation of nonopioid medications among patients with CNCP. SCAN-ECHO-PM may provide a novel means of building pain management competency among primary care providers. Key Words. Telehealth; Pain Management; Primary Care; Anticonvulsants; Antidepressants; Opioids and Physical Therapy
The Extension for Community Healthcare Outcomes (ECHO) model was created to address barriers to specialty care access [9]. The ECHO model uses telehealth technology to provide clinical education and support to primary care providers in the care of patients with complex, chronic conditions “telementoring” [9–11]. The effectiveness of this model was first demonstrated in the management of hepatitis C, and has since been described in the care of patients with other conditions such as HIV, addiction, and chronic pain [12–15]. In 2011, the VHA implemented the ECHO model with the goal of improving Veterans’ access to specialty care in seven VHA networks across parts of 31 states [16]. The Specialty Care Access Network (SCAN-ECHO) includes programs for a range of specialties [16]. SCAN-ECHO for pain management (SCAN-ECHO-PM) targeted chronic pain as a common, complex, chronic disease that is uniquely suited to this model [9]. Though existing ECHO programs targeting chronic pain have shown promise, analyses of these programs have been geographically limited and have not assessed provider behavior or patient-level outcomes [13,15]. The primary aim of this study is to evaluate the impact of the VHA’s SCAN-ECHO-PM program on primary care-based delivery of multidisciplinary pain care, defined as physical medicine, mental health, substance use disorder and specialty pain services, and nonopioid pharmacologic management, defined as antidepressant or anticonvulsant medications. We hypothesized that consultation to the SCAN-ECHO-PM program will increase rates of guideline-concordant pain care delivery among participating providers’ patients with chronic, noncancer pain.
Introduction
Methods
Chronic pain affects about 100 million American adults—more than the total affected by heart disease, cancer and diabetes combined—at a cost of up to $635 billion annually [1]. Nearly, half of all Veterans suffer from at least one chronic pain condition [2]. Expert guidelines and the Veterans Health Administration’s (VHA) National Pain Management Strategy both recommend multidisciplinary pain care and a multimodal approach to analgesic medications, encouraging use of nonopioid analgesics such as antidepressants and
SCAN-ECHO Program In 2011, the VHA implemented SCAN-ECHO-PM simultaneously in 7 of 21 VHA geographic networks [16]. These networks comprise 47 medical centers (including seven coordinating centers) and 148 community-based outpatient clinics [16,17]. The SCAN-ECHO-PM program uses telehealth technology such as videoconferencing to deliver case-based educational sessions to primary care providers with the aim of building primary care provider 1091
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Methods. We identified the patient panels of primary care providers who submitted a consultation to one or more SCAN-ECHO-PM sessions. We constructed multivariable Cox proportional hazards models to assess the association between provider SCAN-ECHO-PM consultation and 1) delivery of outpatient care (physical medicine, mental health, substance use disorder, and pain medicine) and 2) medication initiation (antidepressants, anticonvulsants, and opioid analgesics).
anticonvulsants [3–5]. Specifically, VHA’s National Pain Management Strategy endorses the stepped care model of pain management [6]. This model emphasizes primary care-based assessment and treatment of pain, access to multidisciplinary care including physical medicine, mental health, substance use disorder services and consultation from specialty pain clinics. However, it is challenging for primary care providers to deliver guideline-concordant pain care, and training in pain management is often inadequate [1,7]. Additionally, there remains a shortage of board-certified pain physicians, which is severe in rural areas [8].
Frank et al.
Figure 1 Flow chart of evaluation cohort eligibility and SCAN-ECHO-PM participation. SCAN-ECHOPM 5 Specialty Care Access Network-Extension for Community Health Outcomes for Pain Management.
competencies. Participating providers can subsequently apply these emerging competencies to the care of their entire patient panel. Sessions take place every 1–2 weeks and last 60–90 minutes. Primary care providers submit cases for consultation through an electronic request. During SCAN-ECHO-PM sessions, multidisciplinary teams of pain management specialists (i.e., pain medicine, physical medicine and rehabilitation, psychology, pharmacy, nursing) provide care recommendations on the presented cases as well as didactic presentations. The didactic presentations are based on the VHA National Pain Management Strategy and on VHA/Department of Defense Clinical Practice Guidelines [5,6]. A national curriculum provides guidance to the specialty team at each coordinating site. Providers are encouraged to attend SCANECHO-PM sessions through weekly email reminders announcing upcoming topics, regardless of whether they submitted a case for consultation. Attendance is voluntary though continuing medical education credit is available at no cost for participation. Study Design and Population This study evaluated the implementation of the VHA’s SCAN-ECHO-PM program from July 1, 2011 through December 31, 2013. We used data from the VHA’s Corporate Data Warehouse to identify VHA outpatient 1092
This was a VHA operational evaluation project that was sponsored by the VA Office of Specialty Care Services (SCS)\Specialty Care Transformation (OSCT). The activities undertaken in the conduct of this project were in support of VHA operational programs and did not constitute research, in whole or in part, in compliance with VHA Handbook 1058.05. Therefore, institutional review board approval was not required. Exposure Definition We identified patients whose cases were presented at a SCAN-ECHO-PM session (N 5 256) and each patient’s regular primary care provider (N 5 159). As SCANECHO-PM consultation is a provider-level exposure, we then identified all other patients with CNCP in presenting providers’ patient panels (N 5 22,078). We considered these patients ‘SCAN-ECHO-PM-unexposed’ prior to the date of a linked primary care provider’s first SCAN-ECHO-PM consultation and “SCAN-ECHO-PM exposed” after this date. These patients were considered “SCAN-ECHO-PM exposed” until the end of the evaluation period. Patients who met study eligibility criteria but whose primary care provider did not participate in a SCAN-ECHO-PM session were considered “never exposed.” Outcome Measures Multidisciplinary pain care services were defined as outpatient clinic visits in each of four clinical settings: physical medicine (i.e., physical therapy, occupational therapy, chiropractic care, etc.), mental health, substance use disorder, and pain medicine (Appendix Table A1). Medication utilization was defined as newly initiated and filled prescriptions for medications in each of three
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
and inpatient encounters, and medication records from January 1, 2010 through December 31, 2013. We first identified patients with a documented outpatient clinic visit with a pain numeric rating score (NRS) 4 (N 5 1,235,561) (Figure 1). The NRS rates pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst possible pain [18]. All pain NRS data were collected as part of routine clinical care. We defined chronic pain as a visit with a pain NRS 4 in at least 3 calendar months during a 12-month period, consistent with prior definitions of chronic pain that require at least 3 to 6 months of moderate-to-severe pain [19–21]. We identified patients with 3 visits with the same primary care provider during the study period, and defined patients’ index date as the first observed visit with this primary care provider. We excluded patients who did not meet this definition of a relationship with a primary care provider during the study period (N 5 22,323). We excluded patients with a cancer diagnosis (N 5 48,249), a clinic visit for palliative care or hospice (N 5 17,218) or without any diagnosis data recorded in the year prior to index date (N 5 531). The final evaluation cohort was comprised of 322,435 patients with chronic, noncancer pain (CNCP).
VA SCAN-ECHO for Pain Management
classes: antidepressants, anticonvulsants, and opioid analgesics [22]. To establish baseline utilization, each outpatient clinic utilization outcome and medication utilization outcome was evaluated for 365 days and 90 days prior to the index date, respectively. For each outcome, the first occurrence after the index date was then evaluated. As, we were interested in treatment initiation for each outcome, individuals with utilization prior to the index date were excluded. Covariate Definitions Demographic data included age at index date, gender, and race. To establish baseline comorbidities, we identified diagnoses made by clinicians for pain-relevant conditions at inpatient and outpatient health care encounters in the year prior to the patient’s index date. Diagnoses were based on the International Classification of Diseases, Clinical Modification-9th Revision (ICD-9CM). Pain diagnoses were categorized based on prior research on chronic pain and included back pain, neck and other joint pain, neuropathy, fibromyalgia, irritable bowel disease, and migraine headache [19,20]. Mental health and substance use disorder diagnoses were categorized using validated categories and consistent with prior research [19,23,24]. These categories included schizophrenia, bipolar disorder, depression, anxiety, post-traumatic stress disorder, other mental health diagnoses, alcohol use disorder, opioid use
disorder and other substance use disorders (Appendix Table A2). We created a variable to identify individuals with co-occurring mental health and substance use disorder diagnoses consistent with prior research [25]. To measure the overall burden of medical conditions, we used the Charlson comorbidity index, a commonly used measure adapted for use with administrative data [26]. We identified the home primary care clinic for each Veteran as the clinic at which their primary care provider visits occurred. We established three mutually exclusive categories for these clinics: clinics within VA medical centers, urban community-based clinics, and rural community-based clinics. Clinic rurality was established using the VA Site Tracking (VAST) database. VAST designations are maintained by the VA Office of Rural Health and based on U.S. Census data. Finally, we included a categorical variable for the calendar year of patients’ index date to adjust for temporal trends. Statistical Analysis We used bivariate methods to compare the patient demographics and comorbidities of patients linked to SCAN-ECHO-PM-exposed providers to all other patients with CNCP. We also compared unadjusted rates of clinic utilization in the 365 days prior to patients’ index date and medication utilization in the 90 days prior to patients’ index date. Categorical variables are presented as proportions and were analyzed using 1093
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Figure 2 SCAN-ECHO-PM implementation and evaluation timeline. SCAN-ECHO-PM 5 Specialty Care Access Network-Extension for Community Health Outcomes for Pain Management. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Frank et al.
Table 1 Demographic and clinical characteristics by SCAN-ECHO-PM exposure group (N 5 311,374)
Sample size Age, mean (SD)
Unexposed
P
22,454 58.5 (13.6) 90.9
299,981 58.0 (13.5) 89.8
71.6 17.5 10.9
69.4 21.2 9.4
21.9 65.2 12.9
54.5 36.4 9.1
46.5 68.1 7.4 6.6 3.9 1.3
48.7 70.7 7.4 8.1 4.2 1.5
PRIMARY CARE & HEALTH SERVICES SECTION Original Research Article Evaluation of a Telementoring Intervention for Pain Management in the Veterans Health Administration
*VA Eastern Colorado Health Care System, Denver, Colorado; †Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado; ‡ Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; §Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; ¶VA Puget Sound Health Care System, Seattle, Washington; **Yale University School of Medicine, New Haven, Connecticut; ††VA Connecticut Healthcare System, West Haven, Connecticut; ‡‡Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; §§Office of Specialty Care, Veterans Health Administration, Washington, DC, USA Reprint Requests to: Joseph W. Frank, MD, MPH, Ambulatory Care, VA Eastern Colorado Health Care System, 1055 Clermont Street, Denver, CO 80220, USA. Tel: 317-509-0071; Fax: 303-724-2270; E-mail: [email protected]
Authorship information: Concept and design (all authors); data collection (EPC, JTS); data analysis (EPC); data interpretation (all authors); drafting of the manuscript (JWF); critical revision of the manuscript for important intellectual content (all authors).
Services, Patient Care Services, Veterans Health Administration, Washington DC. Dr. Frank was supported by the VA Eastern Colorado Health Care System and the University of Colorado School of Medicine. Drs. Ho and Au were supported by the Denver-Seattle Center of Innovation for VeteranCentered and Value-Driven Care (DiSCoVVR). Drs. Kerns and Moore were supported by the Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center of Innovation at the VA Connecticut Healthcare System, West Haven, CT. Role of Funders/Sponsors: This project was conducted as part of VHA health care operations in compliance with VHA Handbook 1058.05. The project team had full responsibility for the design and conduct of the operational evaluation activities, as focused on the implementation of transformational initiatives of interest to the VA Office of Specialty Care Services (SCS)\Specialty Care Transformation (OSCT); collection, management, analysis, and interpretation of the data; and preparation of the manuscript. One of the co-authors of the manuscript is employed by OSCT. Previous presentations: An abstract of this study was presented at the Mountain West Regional Meeting of the Society of General Internal Medicine in Denver, CO on October 10, 2014. Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs.
Abstract Conflict of interest: The authors report no conflicts of interest, including relevant financial interests, activities, relationships, and affiliations. Sources of funding: This work was supported by T-21 funds and the Office of Specialty Care Services/Specialty Care Transformation, Office of Specialty Care 1090
Objective. Half of all Veterans experience chronic pain yet many face geographical barriers to specialty pain care. In 2011, the Veterans Health Administration (VHA) launched the Specialty Care Access Network-ECHO (SCAN-ECHO), which uses telehealth technology to provide primary care providers
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Joseph W. Frank, MD, MPH,*,† Evan P. Carey, MS,* Katherine M. Fagan, MPH,* David C. Aron, MD, MS,‡,§ Jeff Todd-Stenberg, BA,¶ Brent A. Moore, PhD,**,†† Robert D. Kerns, PhD,**,†† David H. Au, MD, MS,¶ P. Michael Ho, MD, PhD,*,‡‡ and Susan R. Kirsh, MD, MPH‡,§,§§
VA SCAN-ECHO for Pain Management with case-based specialist consultation and pain management education. Our objective was to evaluate the pilot SCAN-ECHO pain management program (SCAN-ECHO-PM). Design and Setting. This was a longitudinal observational evaluation of SCAN-ECHO-PM in seven regional VHA healthcare networks.
Results. Primary care providers (N 5 159) who presented one or more SCAN-ECHO-PM sessions had patient panels of 22,454 patients with chronic noncancer pain (CNCP). Provider consultation to SCANECHO-PM was associated with utilization of physical medicine [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.05–1.14] but not mental health (HR 0.99, 95% CI 0.93–1.05), substance use disorder (HR 0.93, 95% CI 0.84–1.03) or specialty pain clinics (HR 1.01, 95% CI 0.94–1.08). SCAN-ECHO-PM consultation was associated with initiation of an antidepressant (HR 1.09, 95% CI 1.02–1.15) or anticonvulsant medication (HR 1.13, 95% CI 1.06–1.19) but not an opioid analgesic (HR 1.05, 0.99–1.10). Conclusions. SCAN-ECHO-PM was associated with increased utilization of physical medicine services and initiation of nonopioid medications among patients with CNCP. SCAN-ECHO-PM may provide a novel means of building pain management competency among primary care providers. Key Words. Telehealth; Pain Management; Primary Care; Anticonvulsants; Antidepressants; Opioids and Physical Therapy
The Extension for Community Healthcare Outcomes (ECHO) model was created to address barriers to specialty care access [9]. The ECHO model uses telehealth technology to provide clinical education and support to primary care providers in the care of patients with complex, chronic conditions “telementoring” [9–11]. The effectiveness of this model was first demonstrated in the management of hepatitis C, and has since been described in the care of patients with other conditions such as HIV, addiction, and chronic pain [12–15]. In 2011, the VHA implemented the ECHO model with the goal of improving Veterans’ access to specialty care in seven VHA networks across parts of 31 states [16]. The Specialty Care Access Network (SCAN-ECHO) includes programs for a range of specialties [16]. SCAN-ECHO for pain management (SCAN-ECHO-PM) targeted chronic pain as a common, complex, chronic disease that is uniquely suited to this model [9]. Though existing ECHO programs targeting chronic pain have shown promise, analyses of these programs have been geographically limited and have not assessed provider behavior or patient-level outcomes [13,15]. The primary aim of this study is to evaluate the impact of the VHA’s SCAN-ECHO-PM program on primary care-based delivery of multidisciplinary pain care, defined as physical medicine, mental health, substance use disorder and specialty pain services, and nonopioid pharmacologic management, defined as antidepressant or anticonvulsant medications. We hypothesized that consultation to the SCAN-ECHO-PM program will increase rates of guideline-concordant pain care delivery among participating providers’ patients with chronic, noncancer pain.
Introduction
Methods
Chronic pain affects about 100 million American adults—more than the total affected by heart disease, cancer and diabetes combined—at a cost of up to $635 billion annually [1]. Nearly, half of all Veterans suffer from at least one chronic pain condition [2]. Expert guidelines and the Veterans Health Administration’s (VHA) National Pain Management Strategy both recommend multidisciplinary pain care and a multimodal approach to analgesic medications, encouraging use of nonopioid analgesics such as antidepressants and
SCAN-ECHO Program In 2011, the VHA implemented SCAN-ECHO-PM simultaneously in 7 of 21 VHA geographic networks [16]. These networks comprise 47 medical centers (including seven coordinating centers) and 148 community-based outpatient clinics [16,17]. The SCAN-ECHO-PM program uses telehealth technology such as videoconferencing to deliver case-based educational sessions to primary care providers with the aim of building primary care provider 1091
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Methods. We identified the patient panels of primary care providers who submitted a consultation to one or more SCAN-ECHO-PM sessions. We constructed multivariable Cox proportional hazards models to assess the association between provider SCAN-ECHO-PM consultation and 1) delivery of outpatient care (physical medicine, mental health, substance use disorder, and pain medicine) and 2) medication initiation (antidepressants, anticonvulsants, and opioid analgesics).
anticonvulsants [3–5]. Specifically, VHA’s National Pain Management Strategy endorses the stepped care model of pain management [6]. This model emphasizes primary care-based assessment and treatment of pain, access to multidisciplinary care including physical medicine, mental health, substance use disorder services and consultation from specialty pain clinics. However, it is challenging for primary care providers to deliver guideline-concordant pain care, and training in pain management is often inadequate [1,7]. Additionally, there remains a shortage of board-certified pain physicians, which is severe in rural areas [8].
Frank et al.
Figure 1 Flow chart of evaluation cohort eligibility and SCAN-ECHO-PM participation. SCAN-ECHOPM 5 Specialty Care Access Network-Extension for Community Health Outcomes for Pain Management.
competencies. Participating providers can subsequently apply these emerging competencies to the care of their entire patient panel. Sessions take place every 1–2 weeks and last 60–90 minutes. Primary care providers submit cases for consultation through an electronic request. During SCAN-ECHO-PM sessions, multidisciplinary teams of pain management specialists (i.e., pain medicine, physical medicine and rehabilitation, psychology, pharmacy, nursing) provide care recommendations on the presented cases as well as didactic presentations. The didactic presentations are based on the VHA National Pain Management Strategy and on VHA/Department of Defense Clinical Practice Guidelines [5,6]. A national curriculum provides guidance to the specialty team at each coordinating site. Providers are encouraged to attend SCANECHO-PM sessions through weekly email reminders announcing upcoming topics, regardless of whether they submitted a case for consultation. Attendance is voluntary though continuing medical education credit is available at no cost for participation. Study Design and Population This study evaluated the implementation of the VHA’s SCAN-ECHO-PM program from July 1, 2011 through December 31, 2013. We used data from the VHA’s Corporate Data Warehouse to identify VHA outpatient 1092
This was a VHA operational evaluation project that was sponsored by the VA Office of Specialty Care Services (SCS)\Specialty Care Transformation (OSCT). The activities undertaken in the conduct of this project were in support of VHA operational programs and did not constitute research, in whole or in part, in compliance with VHA Handbook 1058.05. Therefore, institutional review board approval was not required. Exposure Definition We identified patients whose cases were presented at a SCAN-ECHO-PM session (N 5 256) and each patient’s regular primary care provider (N 5 159). As SCANECHO-PM consultation is a provider-level exposure, we then identified all other patients with CNCP in presenting providers’ patient panels (N 5 22,078). We considered these patients ‘SCAN-ECHO-PM-unexposed’ prior to the date of a linked primary care provider’s first SCAN-ECHO-PM consultation and “SCAN-ECHO-PM exposed” after this date. These patients were considered “SCAN-ECHO-PM exposed” until the end of the evaluation period. Patients who met study eligibility criteria but whose primary care provider did not participate in a SCAN-ECHO-PM session were considered “never exposed.” Outcome Measures Multidisciplinary pain care services were defined as outpatient clinic visits in each of four clinical settings: physical medicine (i.e., physical therapy, occupational therapy, chiropractic care, etc.), mental health, substance use disorder, and pain medicine (Appendix Table A1). Medication utilization was defined as newly initiated and filled prescriptions for medications in each of three
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
and inpatient encounters, and medication records from January 1, 2010 through December 31, 2013. We first identified patients with a documented outpatient clinic visit with a pain numeric rating score (NRS) 4 (N 5 1,235,561) (Figure 1). The NRS rates pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst possible pain [18]. All pain NRS data were collected as part of routine clinical care. We defined chronic pain as a visit with a pain NRS 4 in at least 3 calendar months during a 12-month period, consistent with prior definitions of chronic pain that require at least 3 to 6 months of moderate-to-severe pain [19–21]. We identified patients with 3 visits with the same primary care provider during the study period, and defined patients’ index date as the first observed visit with this primary care provider. We excluded patients who did not meet this definition of a relationship with a primary care provider during the study period (N 5 22,323). We excluded patients with a cancer diagnosis (N 5 48,249), a clinic visit for palliative care or hospice (N 5 17,218) or without any diagnosis data recorded in the year prior to index date (N 5 531). The final evaluation cohort was comprised of 322,435 patients with chronic, noncancer pain (CNCP).
VA SCAN-ECHO for Pain Management
classes: antidepressants, anticonvulsants, and opioid analgesics [22]. To establish baseline utilization, each outpatient clinic utilization outcome and medication utilization outcome was evaluated for 365 days and 90 days prior to the index date, respectively. For each outcome, the first occurrence after the index date was then evaluated. As, we were interested in treatment initiation for each outcome, individuals with utilization prior to the index date were excluded. Covariate Definitions Demographic data included age at index date, gender, and race. To establish baseline comorbidities, we identified diagnoses made by clinicians for pain-relevant conditions at inpatient and outpatient health care encounters in the year prior to the patient’s index date. Diagnoses were based on the International Classification of Diseases, Clinical Modification-9th Revision (ICD-9CM). Pain diagnoses were categorized based on prior research on chronic pain and included back pain, neck and other joint pain, neuropathy, fibromyalgia, irritable bowel disease, and migraine headache [19,20]. Mental health and substance use disorder diagnoses were categorized using validated categories and consistent with prior research [19,23,24]. These categories included schizophrenia, bipolar disorder, depression, anxiety, post-traumatic stress disorder, other mental health diagnoses, alcohol use disorder, opioid use
disorder and other substance use disorders (Appendix Table A2). We created a variable to identify individuals with co-occurring mental health and substance use disorder diagnoses consistent with prior research [25]. To measure the overall burden of medical conditions, we used the Charlson comorbidity index, a commonly used measure adapted for use with administrative data [26]. We identified the home primary care clinic for each Veteran as the clinic at which their primary care provider visits occurred. We established three mutually exclusive categories for these clinics: clinics within VA medical centers, urban community-based clinics, and rural community-based clinics. Clinic rurality was established using the VA Site Tracking (VAST) database. VAST designations are maintained by the VA Office of Rural Health and based on U.S. Census data. Finally, we included a categorical variable for the calendar year of patients’ index date to adjust for temporal trends. Statistical Analysis We used bivariate methods to compare the patient demographics and comorbidities of patients linked to SCAN-ECHO-PM-exposed providers to all other patients with CNCP. We also compared unadjusted rates of clinic utilization in the 365 days prior to patients’ index date and medication utilization in the 90 days prior to patients’ index date. Categorical variables are presented as proportions and were analyzed using 1093
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 6, 2016
Figure 2 SCAN-ECHO-PM implementation and evaluation timeline. SCAN-ECHO-PM 5 Specialty Care Access Network-Extension for Community Health Outcomes for Pain Management. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Frank et al.
Table 1 Demographic and clinical characteristics by SCAN-ECHO-PM exposure group (N 5 311,374)
Sample size Age, mean (SD)
Unexposed
P
22,454 58.5 (13.6) 90.9
299,981 58.0 (13.5) 89.8
71.6 17.5 10.9
69.4 21.2 9.4
21.9 65.2 12.9
54.5 36.4 9.1
46.5 68.1 7.4 6.6 3.9 1.3
48.7 70.7 7.4 8.1 4.2 1.5
