Pain and the Health System

1. Pain and the Health System John D. Piette, Ph.D. Associate Professor of General Internal Medicine jpiette@umich.edu

2. The Interplay between Diabetes Management and Management of Comorbid Chronic Pain Patient Resources And Priority for Diabetes Management Diabetes Self-Care Diabetes Self-Management Support Clinician Resources & Priority for Diabetes Mgmt Diabetes-Specific Health Diabetes Medical Management Healthcare Organization Pain Medical Management Non-Diabetes Health Clinician Resources and Priority for Pain Management Pain Self-Management Support Patient Resources and Priorities for Pain Management Pain Self-Care Piette JD, Kerr EA. Diabetes Care 2006.

3. Proportion of VA Patients with Comorbid Chronic Pain

4. Chronic Pain as a Competing Demand in Outpatient Care

5. Time is on [our] side. (Jagger, 1964) But not in outpatient care. (Yarnall, 2003)

6. 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.

7. 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.

8. Self-Rated Health P < .001 P < .001

9. Diabetes Self-Management Problems

10. Medication Adherence and Medication Costs

11. Patient-Clinician Communication Clinician trust Discussion about rx costs and adherence Concrete assistance with rx costs Health System Factors Barriers to refilling rx Difficulty applying for benefits Regimen Complexity # of Rx Frequency of refills Non-Adherence D/T Rx Cost Pt Characteristics And Beliefs Sociocultural influences Perceived benefits of tx Mental status Self-efficacy Health literacy Rx Characteristics side effects convenience of use perceived efficacy Financial Pressures income rx coverage OOP rx costs Other health costs Other Problems D/T Rx Cost Dx Characteristics Effect on current HRQL Effect on life expectancy Conceptual Framework From: Piette, Heisler, Horne, and Alexander, under review.

12. Patient-Clinician Communication Clinician trust Discussion about rx costs and adherence Concrete assistance with rx costs Health System Factors Barriers to refilling rx Difficulty applying for benefits Regimen Complexity # of Rx Frequency of refills Non-Adherence D/T Rx Cost Pt Characteristics And Beliefs Sociocultural influences Perceived benefits of tx Mental status Self-efficacy Health literacy Rx Characteristics side effects convenience of use perceived efficacy Financial Pressures income rx coverage OOP rx costs Other health costs Other Problems D/T Rx Cost Dx Characteristics Effect on current HRQL Effect on life expectancy Conceptual Framework From: Piette, Heisler, Horne, and Alexander, Soc Sci and Med, 2006.

13. Patient-Clinician Communication Clinician trust Discussion about rx costs and adherence Concrete assistance with rx costs Health System Factors Barriers to refilling rx Difficulty applying for benefits Regimen Complexity # of Rx Frequency of refills Non-Adherence D/T Rx Cost Pt Characteristics And Beliefs Sociocultural influences Perceived benefits of tx Mental status Self-efficacy Health literacy Rx Characteristics side effects convenience of use perceived efficacy Financial Pressures income rx coverage OOP rx costs Other health costs Other Problems D/T Rx Cost Dx Characteristics Effect on current HRQL Effect on life expectancy Conceptual Framework From: Piette, Heisler, Horne, and Alexander, Soc Sci and Med, 2006.

14. Predicted Probability of Cost-Related Underuse Among Patients Using Both “Preventive” and “Symptom-Relief” Drugs Piette, Wagner, Heisler M. Am J Clin Epi, 2006. Piette Heisler, Wagner, Am J Pub Hlth 2004.

15. Strategies for Intervention

16. 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).

17. 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

18. 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

19. 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

20. How Does It Work?

21. A Pilot Study

22. 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)

23. 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

24. How Does It Work?

25. 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.

27. Information Flow Caregivers can modify calling schedule and record personalized questions for patients to receive Formal service providers alerted about urgent health problems by fax Caregiver Formal Service Providers IVR System Feedback to caregivers via routine reports on the website and urgent reports via email Immediate feedback to patients about health and behavioral problems reported during IVR calls Patient Patients report health and self-care information weekly

28. Information Flow Caregivers can modify calling schedule and record personalized questions for patients to receive Formal service providers alerted about urgent health problems by fax Caregiver Formal Service Providers IVR System Feedback to caregivers via routine reports on the website and urgent reports via email Immediate feedback to patients about health and behavioral problems reported during IVR calls Patient Patients report health and self-care information weekly

29. 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

30. Design • TRIAD-VA patient surveys (N=993) • ~75% response rate • 5 VAMCs and affiliated CBOCs • 60% reporting chronic pain

31. Descriptive Statistics

32. Regression Results: Self-management Score Adjusting for income, education, insulin, age, sex, race, BMI and clustering by site

33. Patient-Clinician Communication Clinician trust Discussion about rx costs and adherence Concrete assistance with rx costs Health System Factors Barriers to refilling rx Difficulty applying for benefits Regimen Complexity # of Rx Frequency of refills Non-Adherence D/T Rx Cost Pt Characteristics And Beliefs Sociocultural influences Perceived benefits of tx Mental status Self-efficacy Health literacy Rx Characteristics side effects convenience of use perceived efficacy Financial Pressures income rx coverage OOP rx costs Other health costs Other Problems D/T Rx Cost Dx Characteristics Effect on current HRQL Effect on life expectancy Conceptual Framework From: Piette, Heisler, Horne, and Alexander, under review.

34. Patient-Clinician Communication Clinician trust Discussion about rx costs and adherence Concrete assistance with rx costs Health System Factors Barriers to refilling rx Difficulty applying for benefits Regimen Complexity # of Rx Frequency of refills Non-Adherence D/T Rx Cost Pt Characteristics And Beliefs Sociocultural influences Perceived benefits of tx Mental status Self-efficacy Health literacy Rx Characteristics side effects convenience of use perceived efficacy Financial Pressures income rx coverage OOP rx costs Other health costs Other Problems D/T Rx Cost Dx Characteristics Effect on current HRQL Effect on life expectancy Conceptual Framework From: Piette, Heisler, Horne, and Alexander, under review.

35. 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.

36. 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.

37. 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.

38. 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.