Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE)

背景：慢性疼痛影响40-70%的退伍军人，直接医疗费用超过6000亿美元/年 成本和工人生产力的损失。疼痛治疗的种族差异已被广泛记录。 少数民族患者，包括退伍军人，更有可能因疼痛而治疗不足。少数民族的痛苦 记录不太频繁，接受更多的尿液药物测试，更有可能被称为物质 比白色退伍军人的虐待评估。加剧这些疼痛护理的差异，少数退伍军人表现出 患者激活水平低于白人。患者激活-拥有知识、信心和技能， 管理健康-与更好的健康体验，自我管理和结果相关。低活化 通常表现为少数民族患者之间的沟通较差。少数民族患者不太可能 与提供者分享他们的担忧，提出问题，并为他们的诊所访问做准备。这种糟糕的沟通 与较低质量的护理、较差的患者-提供者关系和治疗不依从性相关。的 少数群体所经历的较差的沟通因记录在案的病人的困难而加剧， 关于慢性疼痛及其治疗的提供者沟通，特别是在阿片类药物方面。 目标：合作（沟通和激活疼痛，以加强关系和治疗疼痛） 与公平）是一项实用的随机对照试验的干预，以改善患者的激活， 与黑人退伍军人慢性疼痛的提供者沟通。COOPERATE专注于2项基本技能 促进有效患者激活所需的设置：1）目标设定和优先级，以及2）沟通 skills.合作是通过电话提供6个会议（4个每周会议，然后是2个助推器 会议）为期12周。主要研究结局是患者激活。 方法：COOPERATE是一项混合1型研究，旨在测试有效性，同时检查 执行促进者和障碍。合作将招募250名黑人退伍军人， 肌肉骨骼疼痛从初级保健诊所。退伍军人将被随机分配到合作组织 对于目标1，我们将在目标3（主要终点）测试合作的效果 点）、6个月和9个月（持续效应）对患者激活（主要结局）、沟通自我 疗效、疼痛强度和干扰以及心理功能。目标2将检查患者激活， 临床结果的调解人，以及作为合作对患者影响的调节者的工作联盟 activation.在目标3中，我们的实施前目标，我们将使用定性方法来了解促进者， 实施合作的障碍。在RE-AIM框架的指导下，我们将有目的地采访一位 选择干预退伍军人和初级保健和慢性疼痛诊所的临床医生的子样本， 更好地为合作做好准备。 创新：COOPERATE专注于两个重要但经常被忽视的改进领域， 少数群体健康：患者激活和沟通。这在慢性疼痛护理中尤其重要，因为 存在许多具有广泛风险和益处的治疗选择，由于提供少数群体， 更少的疼痛治疗选择。帮助少数族裔退伍军人在他们的护理中变得更加积极至关重要 来改善慢性疼痛治疗。鉴于VA的努力，如阿片类药物安全性，这一点尤其重要。 倡议，旨在提高退伍军人的安全，但也需要参与，积极的病人作为退伍军人 必须与他们的供应商探索替代疼痛治疗-治疗是可行的退伍军人的 个人的生活方式，并符合他们的症状优先级和治疗目标。

Background: Chronic pain affects 40-70% of Veterans and amounts to over $600 billion/year in direct medical costs and lost worker productivity. Racial disparities in pain treatment have been extensively documented. Minority patients, including Veterans, are more likely to be undertreated for pain. Minority Veterans have pain documented less frequently, undergo more urine drug tests, and are more likely to be referred for substance abuse evaluation than White Veterans. Compounding these pain care disparities, minority Veterans exhibit lower levels of patient activation than Whites. Patient activation—having knowledge, confidence, and skills to manage health—is associated with better health experiences, self-management, and outcomes. Low activation is frequently manifested in poorer communication among minority patients. Minority patients are less likely to share their concerns with providers, ask questions, and prepare for their clinic visits. This poor communication is associated with lower quality care, poorer patient-provider relationships, and treatment non-adherence. The poorer communication experienced by minorities is exacerbated by the documented difficulties in patient- provider communication about chronic pain and its treatment—particularly where opioids are concerned. Objectives: COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) is a pragmatic randomized controlled trial of an intervention to improve patient activation and communication with providers for Black Veterans with chronic pain. COOPERATE focuses on 2 essential skill sets necessary to facilitate effective patient activation: 1) goal-setting and prioritization, and 2) communication skills. COOPERATE is delivered over the telephone in 6 sessions (4 weekly sessions followed by 2 booster session) over a period of 12 weeks. The primary study outcome is patient activation. Methods: COOPERATE is a Hybrid Type 1 study, designed to test effectiveness while also examining implementation facilitators and barriers. COOPERATE will enroll 250 Black Veterans with chronic musculoskeletal pain from primary care clinics. Veterans will be randomized either to the COOPERATE intervention or to an attention control arm. For Aim 1 we will test the effects of COOPERATE at 3 (primary end point), 6, and 9 months (sustained effects) on patient activation (primary outcome), communication self- efficacy, pain intensity and interference, and psychological functioning. Aim 2 will examine patient activation as a mediator of clinical outcomes, and working alliance as a moderator of COOPERATE’s effect on patient activation. In Aim 3, our pre-implementation aim, we will use qualitative methods to understand facilitators and barriers to implementing COOPERATE. Guided by the RE-AIM framework, we will interview a purposefully selected subsample of intervention Veterans, and clinicians from primary care and the chronic pain clinic, to better prepare for COOPERATE’s implementation. Innovation: COOPERATE focuses on two important, yet frequently neglected, areas for improvement in minority health: patient activation and communication. This is especially important in chronic pain care, since numerous treatment options with a wide range of risks and benefits exist, and since minorities are offered fewer of these pain treatment options. Helping minority Veterans to become more active in their care is critical for improving chronic pain care. This is especially important in light of VA efforts such as the Opioid Safety Initiative, designed to improve safety for Veterans, but which also require engaged, active patients as Veterans must explore alternative pain treatments with their providers—treatments that are feasible for Veterans’ individual lifestyles and consistent with their symptom priorities and treatment goals.