Addressing Disparities in Pain Management among Veterans: A Decision Tool to Support Preference-Based Safe Prescribing and Treatment Decisions in Primary Care

解决退伍军人疼痛管理方面的差异：支持初级保健中基于偏好的安全处方和治疗决策的决策工具

• 批准号: 10640628
• 负责人: MARILYN M SCHAPIRA
• 金额: --
• 依托单位: PHILADELPHIA VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-01 至 2024-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10640628
• 关键词: Accident and Emergency department; Acute; Acute Pain; Address; Adoption; Advisory Committees; African American; Age; Black American; Black race; Caring; Categories; Clinic Visits; Clinical; Cognitive; Communication; Communities; Conflict (Psychology); Data; Decision Making; Diagnosis; Disparity; Education; Ensure; Equity; Ethnic Origin; Evaluation; Female; Gender; Guidelines; Health; Health Policy; Health system; Hybrids; Intervention; Intervention Trial; Interview; Measures; Medical center; Methodology; Modification; Online Systems; Opioid; Outcome; Pain; Pain management; Patient Preferences; Patients; Personal Satisfaction; Persons; Philadelphia; Pilot Projects; Population; Primary Care; Process; Professional Organizations; Provider; Race; Recommendation; Research; Risk; Safety; Sampling; Severities; Structure; Symptoms; System; Testing; Time; Trust; United States Department of Veterans Affairs; Veterans; Women' s Health; Work; acute symptom; addiction; alternative treatment; behavioral economics; chronic pain; chronic pain management; clinical care; clinical encounter; cost; effectiveness/implementation trial; evidence base; health disparity; health equity; implicit bias; improved; innovation; integrated care; military veteran; opioid use; pain perception; pain relief; pain symptom; patient oriented; patient-clinician communication; preference; prescription monitoring program; primary care clinic; primary care provider; primary care setting; programs; racial disparity; racial diversity; satisfaction; sex; shared decision making; side effect; support tools; tool; treatment choice; usability; web site; whole health

Background: A common clinical presentation in the primary care setting is of patients with symptoms of acute pain. The effective, safe, respectful, and equitable evaluation, diagnosis, and treatment of pain symptoms is essential for patient well-being. However, provider-patient communication about pain treatment decisions is difficult for many providers, lacks structured information about treatment options, and has led to disparities in adequate pain management and trust. These factors limit the quality of the treatment decision making process. Guidelines for safe prescribing practices related to chronic pain have been developed by the Department of Veterans Affairs and other professional organizations. However, clinicians lack to tools to present patients with evidence based alternative treatment options. Our group has developed and piloted a Web-Based Pain Treatment Option Grid (PainRxOptionGrid) that has been studied in an Emergency Department setting. This tool provides a one screen display of treatment options and evidence-based attributes of each option (Strength, Risk of Addiction, Side Effects, How they Work, Cost, Time to Return to Work). Clinicians can use the tool to limit the choice set as needed and indicate their default recommendation or option for each patient. Patients can then select the attributes that are most important to them and indicate their treatment preference. Together, these features provide a framework for a patient-provider discussion about value-based treatment options for pain control. Usability studies in the ED setting found the tool to be easy to use and acceptable to providers and patients. However, the tool has not been adapted for the Veteran population, for persons of diverse race and gender, or for use in the primary care setting. Significance/Impact: Safe, effective, and equitable control of pain is a priority in provision of primary care for Veterans. A review of HSR&D and ClinicalTrial.gov websites identified no recent or ongoing studies applying principles of shared decision making or developing patient-provider communication strategies for pain treatment in primary care. This work will address a gap in our primary care pain management program. Innovation: The PainRxOptionGrid is innovative in applying principles of SDM and behavioral economics to support the adoption of evidence based, patient-centered, and value aligned decisions in pain management. Specific Aims: Aim 1: To evaluate and adapt the PainRxOptionGrid for use among clinicians and Veterans diverse in race, age, education and gender and for use in the primary care clinical setting. Aim 2: To conduct usability testing of the adapted PainRxOptionGrid among Veterans who present to a primary care clinic with an acute episode of pain defined as having symptoms of pain for less than 4 weeks. Methodology: In Aim 1, we will conduct structured interviews among 12 to15 clinicians and 22 to 36 Veterans in the primary care setting to assess a) barriers and facilitators to use, and b) salience and clarity of the content and format of the PainRxOptionGrid. Findings will inform modification of the tool for this setting and population. In Aim 2, we will conduct usability testing of the modified tool among 26 to 28 Veterans who present to primary care with new acute pain. Sampling will ensure that 40% are Black or African American and 25% are female. Outcomes will include the System Usability Scale, the Decisional Conflict Scale, the Interpersonal Processes of Care scale, pain treatment choice, pain control at 1 week and 1 month, and data on the time spent using the tool in the clinic visit. The study will take place at the Crescenzi VA Medical Center in Philadelphia, PA. Next Steps/ Implementation: This pilot study will provide the data needed to conduct a Hybrid Type 1 Effectiveness-Implementation trial of this intervention. We will work with partners from the Primary Care Pain Initiatives and the Pain Management, Opioid Safety and Prescription Drug Monitoring Programs to integrate our findings and plans for further studies into ongoing National VA initiatives in pain management.

背景：初级保健机构中常见的临床表现是患者出现急性症状 疼痛。对疼痛症状进行有效、安全、尊重和公平的评估、诊断和治疗是 对于患者的健康至关重要。然而，提供者与患者关于疼痛治疗决策的沟通是 对于许多提供者来说很困难，缺乏有关治疗方案的结构化信息，并导致了治疗方案的差异 足够的疼痛管理和信任。这些因素限制了治疗决策过程的质量。 与慢性疼痛相关的安全处方实践指南已由卫生部制定 退伍军人事务部和其他专业组织。然而，临床医生缺乏工具来向患者介绍 基于证据的替代治疗方案。我们的团队开发并试行了基于网络的疼痛 治疗选项网格 (PainRxOptionGrid) 已在急诊科环境中进行了研究。这 工具提供一屏显示治疗选项和每个选项的基于证据的属性 （强度、成瘾风险、副作用、作用原理、成本、重返工作岗位的时间）。临床医生可以使用 该工具可根据需要限制选择集，并为每位患者指示默认建议或选项。 然后患者可以选择对他们来说最重要的属性并表明他们的治疗偏好。 这些功能共同为患者与提供者讨论基于价值的治疗提供了一个框架 疼痛控制的选择。急诊室的可用性研究发现该工具易于使用且易于接受 提供者和患者。然而，该工具尚未针对退伍军人群体、 不同种族和性别，或用于初级保健环境。 意义/影响：安全、有效和公平地控制疼痛是为以下人群提供初级护理的首要任务 退伍军人。对 HSR&D 和 ClinicalTrial.gov 网站的审查发现没有最近或正在进行的研究适用 共同决策的原则或制定患者与提供者之间的疼痛沟通策略 初级保健中的治疗。这项工作将弥补我们初级保健疼痛管理计划中的空白。 创新：PainRxOptionGrid 的创新在于将 SDM 和行为经济学原理应用于 支持在疼痛管理中采用基于证据、以患者为中心和价值一致的决策。 具体目标： 目标 1：评估和调整 PainRxOptionGrid 以供不同种族的临床医生和退伍军人使用， 年龄、教育程度和性别，并用于初级保健临床环境。 目标 2：在向初级人员展示的退伍军人中对改编后的 PainRxOptionGrid 进行可用性测试 护理诊所出现急性疼痛发作，定义为疼痛症状持续少于 4 周。 方法：在目标 1 中，我们将对 12 至 15 名临床医生和 22 至 36 名退伍军人进行结构化访谈 在初级保健环境中评估 a) 使用的障碍和促进因素，以及 b) 内容的显着性和清晰度 和 PainRxOptionGrid 的格式。研究结果将为针对此环境和人群的工具进行修改提供信息。 在目标 2 中，我们将在 26 至 28 名退伍军人中对修改后的工具进行可用性测试。 护理新的急性疼痛。抽样将确保 40% 是黑人或非裔美国人，25% 是女性。 结果将包括系统可用性量表、决策冲突量表、人际过程 护理量表、疼痛治疗选择、第 1 周和第 1 个月的疼痛控制以及使用该工具所花费的时间数据 诊所访问中的工具。该研究将在宾夕法尼亚州费城的 Crescenzi VA 医疗中心进行。 后续步骤/实施：该试点研究将提供进行混合 1 型所需的数据 该干预措施的有效性实施试验。我们将与来自初级保健疼痛的合作伙伴合作 倡议与疼痛管理、阿片类药物安全和处方药监测计划相结合 我们对正在进行的国家退伍军人管理局疼痛管理举措进行进一步研究的发现和计划。