Addressing Disparities In Pain Management

点击翻译按钮获取中文摘要

Background: Disparities in pain treatment suggest that Veterans of color and women Veterans (i.e., “diverse Veterans” in this CDA) are subject to unequal treatment when seeking pain care at VA. Mounting evidence points to the importance of guideline-concordant, evidence-based non-pharmacological pain treatments (NPTs) in the management of chronic pain, yet these treatments are not reaching diverse Veterans. Implementation mapping can be used to rigorously plan implementation of evidence-based practices (e.g., NPTs). Using this approach, one can identify key barriers and facilitators to implementation of evidence-based practices and map them to relevant implementation strategies and target users. The purpose of this CDA is to develop and test a tailored implementation blueprint for increasing NPT use among diverse Veterans. Significance/Impact: Over 2 million Veterans suffer from chronic pain. Over the next four decades, Veterans of color are projected to grow exponentially and there is far more racial/ethnic heterogeneity among women than men in the VA. There is a critical need to identify effective implementation strategies that can be used to disseminate NPTs in order to meet the needs of future diverse Veterans with chronic pain. Innovation: This proposal offers three innovations: 1) An integrated conceptual framework mapping key health equity domains to implementation science solutions; 2) An implementation blueprint developed using a comprehensive and rigorous pre-implementation planning approach (i.e., implementation mapping) that is informed by mixed methods research with target users; and 3) a strong focus on health equity and inclusion of diverse Veteran engagement via operational partnerships during each stage of research. Specific Aims: 1) Aim 1: Understand and identify factors driving NPT use among diverse Veterans using mixed methods; Sub-Aim 1.1: Identify sites at which diverse Veterans are not using NPTs despite NPTs being available; Sub-Aim 1.2: Evaluate multi-level stakeholder perspectives necessary for designing an implementation blueprint tailored for diverse Veterans; Sub-Aim 1.3: Assess disparities in NPT use in VA administrative data; 2) Aim 2: Use implementation mapping to identify core and non-core components of NPT uptake and design an implementation blueprint tailored for diverse Veterans; Sub-Aim 2.1: Generate a matrix of change outcomes resulting from use of a tailored implementation blueprint; Sub-Aim 2.2: Develop protocols and materials comprising the tailored implementation blueprint; and 3) Aim 3: Measure pre-implementation outcomes of the tailored blueprint developed in Aim 2, including feasibility, acceptability, appropriateness, dose, complexity, and self-efficacy among target users. Methodology: In Aim 1.1, a quantitative sampling strategy using VA administrative will inform the selection of four implementation sites. In Aim 1.2, qualitative interviews will identify factors driving NPT use among diverse Veterans, which will, in turn, inform the selection of patient and organizational factors in Aim 1.3 quantitative analyses. In Aim 2.1, we will use implementation mapping and synthesize findings from Aim 1 to develop a needs assessment and design an implementation blueprint. In Aim 2.2, we will develop blueprint protocols and materials comprising patient- and provider-facing implementation strategies that promote the ideas of “push” (e.g., academic detailing) and “pull” (e.g., direct-to-patient outreach) In Aim 3, the implementation blueprint will be assessed among providers and diverse Veterans for pre-implementation outcomes of acceptability, feasibility, appropriateness, dose, and complexity using evaluation surveys and interviews. Next Steps/Implementation: These findings will inform the development of two HSR&D investigator-initiated research (IIR) proposals to be submitted in Years 3 and 5 of the CDA. Notably, this approach can inform the future implementation of evidence-based care across VA and other health systems.