MOTIVATE to Improve Outcomes for Older Veterans with Musculoskeletal Pain and Depression

背景：肌肉骨骼(MSK)疼痛是致残和生活质量下降的主要原因 上了年纪的人。我们还知道，抑郁症状经常与MSK疼痛并存，并并发 管理层。尽管由于MSK疼痛和抑郁症状而导致的成本上升，但很少有行为 已经制定了干预措施，以解决这一脆弱老龄化人口中的这些并存状况。 意义：在VA HSR&D CDA2期间，PI开发并测试了一种新的行为方式的可行性 针对患有慢性背痛和抑郁症状的老年退伍军人进行干预。激励(转移到 改善老年退伍军人的疼痛和抑郁)结合了激励的循证成分 面谈(MI)、价值观启发、目标设定和患者激励，以激励老年退伍军人成为 更多的体力活动，从而改善疼痛干扰、功能和抑郁症状。激励是 由健康教练通过电话或视频在12周的8个疗程中讲授。初步调查结果 从PI正在进行的Motivate试点试验中可以看出，它是可行的，可以改善步数、疼痛干扰和 抑郁症状。针对退伍军人事务部HSR&D优先研究领域，本应用重点改进 获得保健，增加初级保健做法的资源--特别是在疼痛领域 管理和老龄化，并利用虚拟护理向易受伤害的退伍军人提供行为干预。 创新/影响：这项研究具有创新性，因为我们1)同时针对MSK疼痛和抑郁 症状和增强我们发现的概括性，2)结合老年退伍军人改变的动机作为 一个关键的行为决定因素，3)使用远程分娩来扩大疼痛和心理健康服务的覆盖范围 老年退伍军人；以及4)老年退伍军人和其他利益攸关方参与发展的每个阶段。 具体目标：我们提出了一项混合型1型实施-有效性随机对照试验 建立大型退伍军人网站激励的有效性和可扩展性。这项研究的总体目标是 1)检查与等待列表控制臂相比，激励在临床和行为方面的有效性 结果；2)探索激励性干预的实施过程；3)初步评估 对患有慢性MSK疼痛和抑郁的老年退伍军人进行激励的成本和预算影响分析 症状。我们假设，激励将改善这一人群的临床和行为结果。 方法：我们将招募有MSK疼痛和抑郁症状的老年退伍军人(n=264)来确定 激励与等待控制手臂在3岁时改善临床和行为结果的有效性 (主要终点)和注册后6个月。主要结果是疼痛干扰( 简明疼痛清单)和次要结果包括抑郁症状(PHQ-9)、疼痛强度、关节炎 自我效能感、疼痛灾害性量表、Promis量表(包括睡眠)、弹性、脆弱和全局性 变化的印象。使用意向处理分析，我们将在以下方面比较激励组和等待名单组 通过使用线性混合效应模型同时模拟所有 包括基线在内的可用测量。同时，我们将研究以下实施过程： 提供激励(目标2)。使用半结构化访谈，我们将探索背景因素、障碍 和促进者，在退伍军人、一线提供者、卫生保健人员中实施和采用激励 教练和场馆负责人(n~50人)。我们将使用i-PARIHS实施框架向 讨论指南。目标3将提供必要的激励成本评估以及预算影响 从退伍军人管理局的角度进行分析，以估计实施激励的成本。 执行/下一步：成果将促进国家执行和传播激励措施， 以及混合类型3试验，它可以加强初级保健、精神健康和 专门服务，以改善患有MSK疼痛和抑郁症状的老年退伍军人的预后。

Background: Musculoskeletal (MSK) pain is the leading cause of disability and reduced quality of life among older adults. We also know that depressive symptoms frequently co-exist with MSK pain and complicate management. Despite rising costs attributed to MSK pain and depressive symptoms, few behavioral interventions have been developed to address these comorbid conditions in this vulnerable aging population. Significance: The PI, during her VA HSR&D CDA2, developed and tested the feasibility of a novel behavioral intervention targeting older Veterans with chronic back pain and depressive symptoms. MOTIVATE (Moving to Improve Pain and Depression in Older Veterans) incorporates evidence-based components of motivational interviewing (MI), values elicitation, goal setting and patient activation to motivate older Veterans to become more physically active, thereby improving pain interference, function, and depressive symptoms. MOTIVATE is delivered by a health coach via telephone or video during eight sessions over 12-weeks. Preliminary findings from the PI’s ongoing pilot trial of MOTIVATE show it is feasible, improves step counts, pain interference, and depressive symptoms. In response to VA HSR&D research priority areas, this application focuses on improving access to care, augmenting resources for primary care practices – specifically in the areas of pain management and aging, and leveraging virtual care to deliver behavioral interventions to vulnerable Veterans. Innovation/Impact: This research is innovative because we 1) target both MSK pain and depressive symptoms and enhance generalizability of our findings, 2) incorporate older Veterans’ motivation to change as a key behavioral determinant, 3) use remote delivery to enhance reach of both pain and mental health services to older Veterans; and 4) involved older Veterans and other stakeholders at every stage of development. Specific Aims: We propose a hybrid type 1 implementation-effectiveness randomized controlled trial at two large VA sites to establish the effectiveness and scalability of MOTIVATE. The overall goals of this study are to 1) examine the effectiveness of MOTIVATE compared to a waitlist control arm on clinical and behavioral outcomes; 2) explore implementation processes for the MOTIVATE intervention, and 3) evaluate preliminary cost with a budget impact analysis for MOTIVATE in older Veterans with chronic MSK pain and depressive symptoms. We hypothesize that MOTIVATE will improve clinical and behavioral outcomes in this population. Methodology: We will recruit older Veterans with MSK pain and depressive symptoms (n=264) to determine effectiveness of MOTIVATE versus waitlist control arm to improve clinical and behavioral outcomes at 3 (primary endpoint) and 6 months post-enrollment. The primary outcome is pain interference (a subscale of the Brief Pain Inventory) and secondary outcomes include depressive symptoms (PHQ-9), pain intensity, arthritis self-efficacy, pain catastrophizing Scale, PROMIS scales (including sleep), resilience, frailty, and Global Impression of Change. Using intent-to treat analyses, we will compare MOTIVATE and waitlist groups in terms of primary and secondary outcomes by using a linear mixed-effects model which simultaneously models all available measurements including baseline. Concurrently we will examine implementation processes of delivering MOTIVATE (Aim 2). Using semi-structured interviews, we will explore the contextual factors, barriers and facilitators to implementation and uptake of MOTIVATE, among Veterans, frontline providers, health coaches, and facility leaders (n~50). We will use the i-PARIHS implementation framework to inform the discussion guide. Aim 3 will provide necessary cost evaluation of MOTIVATE along with budget impact analysis from the perspective of a VA facility to estimate the costs of implementing MOTIVATE. Implementation/Next Steps: Results will facilitate national implementation and dissemination of MOTIVATE, along with a hybrid type 3 trial, which can augment the care provided by primary care, mental health, and specialty services to improve outcomes in older Veterans with comorbid MSK pain and depressive symptoms.