Pain and the Health System John D. Piette, Ph.D. Associate Professor of General Internal Medicine...

Pain and the Health System

John D. Piette, Ph.D.Associate Professor of General Internal Medicine

[email protected]

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Diabetes Self-Management Support

Pain MedicalManagement

Diabetes MedicalManagement

Patient Resources andPriorities for PainManagement

Clinician Resources & Priority for Diabetes Mgmt Diabetes-Specific

Health

Diabetes Self-Care

Pain Self-Care

PainSelf-Management Support

Non-Diabetes Health

Patient ResourcesAnd Priority for DiabetesManagement

Clinician Resources and Priority for Pain Management

The Interplay between Diabetes Management and Management of Comorbid Chronic Pain

Piette JD, Kerr EA. Diabetes Care 2006..

Proportion of VA Patients with Comorbid Chronic Pain

0

20

40

60

80

100

Diabetes CHF General

% o

f P

atie

nts

Chronic Pain as a Competing Demand in Outpatient Care

Time is on [our] side. (Jagger, 1964)

But not in outpatient care. (Yarnall, 2003)

To fully satisfy the USPSTF recommendations, 1,773 hours of a physician’s annual time, or 7.4 hours per working day is needed in the provision of preventive services.

Yarnall KS, Pollak KI, Ostbye T, et al. Primary care: Is there enough time for prevention? AJPH 2003;93:645-641.

The Effect of Chronic Pain on Diabetes Patients’ Self-Management

Krein SL, Heisler M, Piette JD, et al. The effect of chronic pain on diabetes patients’ self-management. Diabetes Care 2005;28:65-70.

Self-Rated Health

0

10

20

30

40

50

60

Depression Fair/Poor Health

% o

f P

atie

nts

Pain No Pain

P < .001P < .001

Diabetes Self-Management Problems

Chronic Pain(n = 557)

No Chronic Pain(n = 371)

P-value

Rx Problem 8% 4% .01

Activity Problem 73% 43% <.001

Dietary Problem 54% 37% <.001

Footcare Problem 15% 9% .01

Monitoring Problem 19% 15% .13

Medication Adherence and Medication Costs

Conceptual Framework

Non-AdherenceD/T Rx Cost

Other Problems D/T Rx Cost

Financial Pressures income rx coverage OOP rx costs Other health costs

Health System Factors Barriers to refilling rx Difficulty applying for benefits

Pt CharacteristicsAnd Beliefs Sociocultural influences Perceived benefits of tx Mental status Self-efficacy Health literacy

Regimen Complexity # of Rx Frequency of refills

Patient-Clinician Communication Clinician trust Discussion about rx costs and adherence Concrete assistance with rx costs

Rx Characteristics side effects convenience of use perceived efficacy

Dx Characteristics Effect on current HRQL Effect on life expectancy

From: Piette, Heisler, Horne, and Alexander, under review.











From: Piette, Heisler, Horne, and Alexander, Soc Sci and Med, 2006.

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

0.50

Preventive Medications Symptom-Relief Medications

CAD

HTN

CHF

MI

DM

Stroke

Chol

Osteop

COPD

Migraine

Hrt Burn

Asthma

Depress

Arthritis

Back Pain

Ulcer

.17

.28.27.27.26

.25.24

.29.24

.22.20.20.18

.18

.33.29

Piette, Wagner, Heisler M. Am J Clin Epi, 2006.Piette Heisler, Wagner, Am J Pub Hlth 2004.

Predicted Probability of Cost-Related Underuse Among Patients Using Both “Preventive” and “Symptom-Relief” Drugs

Strategies for Intervention

Clinicians should play a consistent and realistic role in a larger system that brings together partners, information technology, and community resources. Attention will increasingly turn to the responsibility of managers of healthcare systems to build the infrastructure to make that happen.

(Stange et al. AJPM 2002).

• Collaboration with support of the UM FGP, UMHS, VA HSR&D, BCBSF, and other organizations

• Leadership includes researchers, administrators, and clinicians throughout UMHS

• Goal is to develop novel, relevant strategies for improving chronic illness care at UM and beyond

• Using the RE-AIM framework to set priorities

• Moving beyond a one-size-fits-all approach to a portfolio of strategies that meet the needs of a diverse patient pool

• Augmenting clinicians’ reach while keeping care coordination within their team

Technology-Assisted Peer Support

Telephone case management programs require nursing resources that many health systems lack

Peer support may help, but patients may have concerned about privacy

Many patients lack the initiative or organization to ensure that contacts are made regularly

From a health system perspective, telephone peer support initiatives are difficult to integrate with other care management services

How Does It Work?

A Pilot Study

Quote from Diabetes Pilot Study

• “A lot of old people like us sit around at home and look out the window. We feel sick and pretty useless. I learned things I could be doing to take care of myself from [my peer partner]. But I also felt that I helped him. I enjoyed talking to him on the phone, and it made me feel inspired to do more.”

(Heisler M, Piette JD, Diab Educ, 2005)

Supporting Informal Care Providers

• Many patients need frequent support with problems that go below the health system’s radar

• Growing numbers of patients live alone

• Informal care providers lack the skills or structure to be effective in assisting with self-care

How Does It Work?

In Conclusion

• Chronic pain is a serious, often ignored problem in traditional health systems.

• Pain can have pervasive effects on chronically-ill patients clinical care and self-management.

• There are real limits on what can be done to address these issues within the context of traditional, face-to-face outpatient visits.

• There are things we can do to improving the care of patients with pain. Strengthening between-visit support and bolstering informal systems of care could help.

IVR System Formal Service Providers

Patient

Caregiver

Patients report health and self-care information weekly

Feedback to caregivers via routine reports on the website and urgent reports via email

Caregivers can modify calling schedule and record personalized questions for patients to receive

Immediate feedback to patients about health and behavioral problems reported during IVR calls

Formal service providers alerted about urgent health problems by fax

Information Flow

An Ongoing RCT

• To evaluate the effect of group visits + IVR-facilitated peer support on diabetes patients’ glycemic control and insulin use;

• To assess the impact of the intervention on key patient-centered outcomes

• To identify patient characteristics associated with willingness to participate in the intervention and mediators of the intervention’s impact on patient outcomes

Design

• TRIAD-VA patient surveys (N=993)

• ~75% response rate

• 5 VAMCs and affiliated CBOCs

• 60% reporting chronic pain

Descriptive Statistics

Chronic Pain(n = 557)

No Chronic Pain(n = 371)

P-value

Mean Age 64 66 <.001

% insulin 44 36 .01

% Men 96 99 .008

% White 67 71 .16

Mean BMI 31.5 29.5 <.001

% High School+ 83 81 .53

Regression Results: Self-management Score

Beta 95% CI P

Chronic Pain -5.0 -7.8 to -2.2 .002

CES-D 10 -6.6 -8.9 to -4.3 .000

Health fair/poor -3.7 -6.2 to -1.1 .008

1 Pain .72 -.87 to 2.3 .350

2 comorbidities

-1.5 -3.5 to .41 .110

DM not priority -4.9 -8.1 to -1.8 .004

Adjusting for income, education, insulin, age, sex, race, BMI and clustering by site











From: Piette, Heisler, Horne, and Alexander, under review.

Low Trust (N=332) High Trust (N=533)

% P-value % P-value

Rx Cost

$1-$50 4.2 <.001

$51-$100 12.1

>$100 29.6

Income

$25K+

$15K - $24K

$10 - $14K

< $10K

Prevalence of Cost-Related Medication Underuse within Subgroups of VA Diabetes Patients Defined by Physician Trust

From: Piette, Heisler, Krein, and Kerr. Arch Int Med, 2005.


% P-value % P-value

Rx Cost

$1-$50 4.2 <.001 3.6 .01

$51-$100 12.1 6.6

>$100 29.6 11.0

Income

$25K+

$15K - $24K

$10 - $14K

< $10K


From: Piette, Heisler, Krein, and Kerr. Arch Int Med, in press.


% P-value % P-value

Rx Cost

$1-$50 4.2 <.001 3.6 .01

$51-$100 12.1 6.6

>$100 29.6 11.0

Income

$25K+ 8.2 .04

$15K - $24K 7.1

$10 - $14K 17.7

< $10K 18.2




% P-value % P-value

Rx Cost

$1-$50 4.2 <.001 3.6 .01

$51-$100 12.1 6.6

>$100 29.6 11.0

Income

$25K+ 8.2 .04 5.9 .6

$15K - $24K 7.1 7.7

$10 - $14K 17.7 4.3

< $10K 18.2 4.2



Pain and the Health System John D. Piette, Ph.D. Associate Professor of General Internal Medicine...

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