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

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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.