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

背景：初级保健环境中的一种常见临床表现是患者出现急性 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 对病人的健康至关重要。然而，关于疼痛治疗决定的提供者和患者之间的沟通是 对许多提供者来说很困难，缺乏关于治疗选择的结构化信息，并导致在 足够的痛苦管理和信任。这些因素限制了治疗决策过程的质量。 与慢性疼痛有关的安全处方做法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为患者提供 基于证据的替代治疗选择。我们的团队已经开发并试点了一种基于网络的痛苦 已在急诊科环境中研究的治疗选项网格(PainRxOptionGrid)。这 该工具提供治疗选项和每个选项的基于证据的属性的单屏幕显示 (体力、上瘾风险、副作用、作用方式、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，并为每个患者指明其默认建议或选项。 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。 总之，这些功能为患者和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。ED环境中的可用性研究发现，该工具易于使用，并可接受 提供者和患者。然而，该工具并不适用于退伍军人，也不适用于 不同的种族和性别，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提供初级保健的优先事项 退伍军人。对HSR&D和ClinicalTrial.gov网站的审查发现，最近或正在进行的研究没有应用 共同决策的原则或为疼痛制定患者-提供者沟通策略 初级保健中的治疗。这项工作将解决我们初级保健疼痛管理计划中的一个缺口。 创新：PainRxOptionGrid在应用SDM和行为经济学原理方面具有创新性 支持在疼痛管理中采用以证据为基础、以患者为中心和与价值一致的决策。 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，并在初级保健临床环境中使用。 目标2：在参加初选的退伍军人中进行修改后的PainRxOptionGrid的可用性测试 有急性疼痛发作的护理诊所，定义为疼痛症状持续不到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)使用的障碍和促进者，以及b)内容的突出度和清晰度 和PainRxOptionGrid的格式。调查结果将通知针对此设置和人口的工具的修改。 在目标2中，我们将在26至28名向小学提交报告的退伍军人中对修改后的工具进行可用性测试 照顾新的急性疼痛。抽样将确保40%是黑人或非裔美国人，25%是女性。 结果包括系统可用性量表、决策冲突量表、人际过程量表 护理量表、疼痛治疗选择、1周和1个月的疼痛控制，以及使用 诊所就诊中的工具。这项研究将在宾夕法尼亚州费城的克雷森西退伍军人医学中心进行。 下一步/实施：此试点研究将提供实施混合类型1所需的数据 有效性--这项干预措施的实施试验。我们将与初级护理痛苦协会的合作伙伴合作 计划与疼痛管理、阿片类药物安全和处方药监测计划相结合 我们的发现和对正在进行的国家退伍军人管理局疼痛管理倡议的进一步研究计划。

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.