pain and the health system john d. piette, ph.d. associate professor of general internal medicine...
Post on 21-Dec-2015
217 views
TRANSCRIPT
Pain and the Health System
John D. Piette, Ph.D.Associate Professor of General Internal Medicine
Hea
lthc
are
Org
aniz
atio
n
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.
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, Soc Sci and Med, 2006.
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, 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
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
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.
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.
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.
Low Trust (N=332) High Trust (N=533)
% 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
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, in press.
Low Trust (N=332) High Trust (N=533)
% 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
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, in press.
Low Trust (N=332) High Trust (N=533)
% 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
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, in press.