Stepped care model of pain management and quality of pain care in long-term opioid therapy.

INTRODUCTION Chronic pain poses a substantial burden on the health of the U.S. population. Estimates suggest that over 100 million Americans experience persistent pain [1-2], with higher prevalence among Veterans [3] as well as medically underserved populations [4]. Among Veterans treated at Veterans Health Administration (VHA) primary care clinics, 50 percent report persistent pain [3,5]. A recent study in a large Federally qualified health center (FQHC) found that 40 percent of all adult ambulatory visits involved patients with chronic pain [6]. In addition, costs are estimated to exceed $600 billion in medical expenses and lost productivity [7]. Although specialized multidisciplinary pain treatment is necessary and effective, particularly for more complex patients [8-9], access to these services is limited and is often not needed [7,10]. Thus, while most patients with chronic pain are treated by a primary care provider (PCP), most PCPs face organizational and administrative barriers to providing effective care [11], receive limited training in pain management [12-13], express low confidence in their ability to care for such patients [14-17], and hold reservations regarding treatment of chronic pain. Studies suggest that there is wide variability in PCPs' adherence to guidelines for pain management [18-20], and documentation of comprehensive pain care plans and specific treatment provided is poor [21-22]. Effective models of pain management in primary care have been developed. The most widely promoted evidence-based model is the Stepped Care Model for Pain Management (SCM-PM). The model, advocated by the American Academy of Pain Medicine [23], is the basis for the VHA's national pain management strategy [24-29]. It emphasizes an individualized, stepwise approach to pain management as patients increase in complexity and/or fail to achieve treatment goals with more conservative interventions [30]. Although several studies have demonstrated the potential for quality improvement initiatives to increase the quality of pain management, such initiatives are limited by a lack of well-established quality measures and benchmarks to measure their effect [6,22,30-32]. Recently, our group developed and validated a new tool for extracting information from electronic health records (EHRs) on the quality of documentation of pain and pain management [33]. Three dimensions of pain care quality were targeted, namely pain assessment (e.g., assessment of functioning and pain interference), treatment plans (e.g., patient education), and pain reassessment (i.e., assessment of outcomes). The current study was designed to further examine the psychometric properties of the measure with a specific focus on examining its responsivity to change in the context of a 5 yr performance improvement project designed to promote implementation of the SCM-PM with a specific focus on improved management of patients receiving long-term opioid therapy. Here we examine outcomes in one multisite VHA healthcare system, with replication and crossvalidation of the utility of this measurement approach in another multisite FQHC that was conducting a similar SCM-PM-based quality improvement initiative. METHODS Setting and Intervention Department of Veterans Affairs Connecticut Healthcare System The Department of Veterans Affairs Connecticut Healthcare System (VACHS) is composed of two academically affiliated VHA medical centers and six community-based outpatient clinics. About 50,000 Veterans receive care within VACHS annually. In addition to primary care services provided by an interdisciplinary team consistent with VHA's Patient Aligned Care Team model of care [34], VACHS PCPs and patients have access to a range of specialty pain management services, including rehabilitation, mental health, pain medicine, and complementary and integrative approaches. Project Step was a 5 yr study designed to examine the adoption and implementation of SCM-PM throughout VACHS, with a particular emphasis on improvements to pain management in the primary care setting and appropriate referral to secondary specialty care [28]. …