Karleen Giannitrapani
Instructor, Medicine - Primary Care and Population Health
Bio
Research Focus: In contrast to bounded teams with static membership, dynamic teaming reflects the common challenge of interdisciplinary healthcare teams with changing rosters. Such dynamic collaboration is critical to addressing multi-faceted problems and individualizing care. At present, off the shelf interventions to improve the way healthcare teams work - often assume static and bounded teams. I intend to leverage design approaches to build a new kind of healthcare “teaming intervention,” which respects the nature of their constantly changing membership and more closely aligns with how healthcare teams actually collaborate.
Expertise: My expertise includes organizational behavior, building interdisciplinary teams, implementation science, mixed methods-research, quality improvement, pain and palliative care research, and global health.
Positions: I am an Instructor in the Division of Primary Care and Population Health at Stanford University School of Medicine and a Core Investigator at the Center for Innovation to Implementation (Ci2i) in the VA Palo Alto Health Care System where I am PI or co-investigator on multiple ongoing studies representing over 25 million dollars of competitive government grant funding. I am also a Director of the VA Quality Improvement Resource Center (QuIRC) for Palliative Care, supporting Geriatrics and Extended Care programs for 170 Veterans Affairs facilities nationally. In QuIRC I lead a portfolio of projects on improving the processes that interdisciplinary teams can leverage to improve pain and symptom management among high-risk patients; specifically I’m aiming to bridge the gap of poor palliative care integration in the perioperative period.
Accomplishments: I have over 50 peer reviewed publications in high quality medical and health services delivery journals such as Medical Care, JAMA Surgery, the Journal of General Internal Medicine, the Journal of Pain and Symptom Management and Pain Medicine. I recently received a 5-year VA Career Development Award on building better teams across disciplines and am an American Academy of Hospice and Palliative Medicine Research Scholar for related work.
Professional Education
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BA, Boston University, Anthropology and Religion (2006)
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MA, University of California Los Angeles, African Studies (2010)
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MPH, University of California Los Angeles, Public Health (2010)
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PhD, University of California Los Angeles, Health Policy & Management Concentration: Organizational Behavior (2015)
All Publications
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Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans.
Journal of pain and symptom management
2023
Abstract
CONTEXT: Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively.OBJECTIVES: To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons.METHODS: We conducted semi-structured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8).RESULTS: Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: (1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; (2) establish risk assessment processes to identify patients who may benefit from a PC consult; (3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; (4) provide sufficient resources to allow for an interdisciplinary sharing of care.CONCLUSION: The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.
View details for DOI 10.1016/j.jpainsymman.2023.08.021
View details for PubMedID 37643653
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The Team-based Serious Illness Care Program, a qualitative evaluation of implementation and teaming.
Journal of pain and symptom management
2023
Abstract
CONTEXT: Earlier and more frequent serious illness conversations with patients allow clinical teams to better align care with patients' goals and values. Non-physician clinicians often have unique perspectives and understanding of patients' wishes and are thus well-positioned to support conversations with seriously ill patients. The Team-based Serious Illness Care Program (SICP) at Stanford aimed to involve all care team members to support and conduct serious illness conversations with patients and their caregivers and families.OBJECTIVES: We conducted interviews with clinicians to understand how care teams implement team-based approaches to conduct serious illness conversations and navigate resulting team complexity.METHODS: We used a rapid qualitative approach to analyze semi-structured interviews of clinician and administrative stakeholders in two Team-based SICP implementation groups (i.e., inpatient oncology and hospital medicine) (n=25). Analysis was informed by frameworks/theory: cross-disciplinary role agreement, team formation and functioning, and organizational theory.RESULTS: Implementing Team-based SICP was feasible. Theme 1 centered on how teams formed and managed to come to agreement: teams with rapidly changing staffing/responsibilities prioritized communication, whereas teams with consistent staffing/responsibilities primarily relied on protocols. Theme 2 demonstrated that leaders and managers at multiple levels could support implementation. Theme 3 explored strengths and opportunities. Positively, Team-based SICP distributed work burden, timed conversations in alignment with patient needs, and added unique value from non-physician team members. Role ambiguity and conflict were attributed to miscommunication and ethical conflicts.CONCLUSION: Team-based serious illness communication is viable and valuable, with a range of successful workflow and leadership approaches.
View details for DOI 10.1016/j.jpainsymman.2023.01.024
View details for PubMedID 36764413
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Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations.
JAMA network open
2023; 6 (2): e2255407
Abstract
Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery.To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery.This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022.Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more.Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation.Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47).Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.
View details for DOI 10.1001/jamanetworkopen.2022.55407
View details for PubMedID 36757697
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"It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period.
Journal of pain and symptom management
2023
Abstract
CONTEXT: Palliative care (PC) interventions improve quality outcomes for surgical patients, yet they are underutilized in the perioperative period. Developing cross-disciplinary provider relationships increases PC consults. However, the attributes of collaborative relationships and how they evolve are unclear.OBJECTIVES: To identify perceptions of PC providers and surgeons on how collaborative cross-disciplinary relationships are built and maintained in the perioperative period.METHODS: This cross-sectional multiphase qualitative study included 23 semi-structured interviews with 10 PC teams (20 providers) and 13 surgeons at geographically distributed Veteran Health Administration (VHA) sites. An analytic approach relied on team-based thematic analysis with a dual review.RESULTS: Respondents defined successful collaborative work relationships between PC and surgeons as having the following features: (1) mutual trust; (2) mutual respect; (3) perceived usefulness; (4) shared clinical objectives; (5) effective communication; and (6) organizational enablers. In addition, the analysis elucidated a framework of six strategies for developing collaborative relationships between PC and surgical teams in the perioperative period: (1) Being present, available, and responsive; (2) Understanding roles; (3) Establishing communication; (4) Recognizing an intermediary and connecting role of supporting team members; (5) Working as a team; and (6) Building on previous experiences.CONCLUSIONS: The study informs future interventions to improve the quality of care for seriously ill patients by better-involving palliative care in the perioperative period. Future work will extend this approach to incorporate the perspectives of patients on their providers' collaboration and how it impacts patient-related outcomes at the intersection of PC and surgery.
View details for DOI 10.1016/j.jpainsymman.2022.12.140
View details for PubMedID 36646332
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Palliative Care and End-of-Life Outcomes Following High-Risk Surgery.
JAMA surgery
2020
Abstract
Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.Design, Setting, and Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.Exposures: Palliative-care consultation within 30 days before or 90 days after surgery.Main Outcomes and Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.Results: A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P=.007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P=.004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P=.05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.Conclusions and Relevance: Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.
View details for DOI 10.1001/jamasurg.2019.5083
View details for PubMedID 31895424
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What Patients Facing Cancer and Caregivers Want From Communication in Times of Crisis: A Qualitative Study in the Early Months of the COVID-19 Pandemic.
The American journal of hospice & palliative care
2023: 10499091231187351
Abstract
Interpersonal communication is a cornerstone of patient-centered care. We aimed to identify what patients with cancer and caregivers may want from communication during a public health crisis.We interviewed 15 patients (8 Veteran, 7 non-Veteran) and caregivers from regionally, racially, and ethnically diverse backgrounds across the US about serious illness care and quality of care during the COVID-19 pandemic Using an iterative, inductive and deductive process, 2 coders analyzed content associated with the code "Communication," which appeared 71 times, and identified 5 themes.Participants identified as White (10), Latino/a (3), Asian (1), and Black (1). (1) Help patients and caregivers prepare for care during crisis by communicating medical information directly and proactively. (2) Explain how a crisis might influence medical recommendations and impact on recovery from illness. (3) Use key messengers to improve communication between primary teams, patients, and caregivers. (4) Include caregivers and families in communication when they cannot be physically present. (5) Foster bidirectional communication with patients and families to engage them in shared decision-making during a vulnerable time.Communication is critical during a public health crisis yet overwhelmed clinicians may not be able to communicate effectively. Communicating with caregivers and family, transparent and timely communication, ensuring diverse providers are on the same page, and effective listening are known gaps even before the COVID-19 pandemic. Clinicians may need quick interventions, like education about goals of care, to remind them about what seriously ill patients and their caregivers want from communication and offer patient-centered care during crises.
View details for DOI 10.1177/10499091231187351
View details for PubMedID 37390466
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Serious illness care quality during COVID-19: Identifying improvement opportunities in narrative reports from a National Bereaved Family Survey.
Palliative medicine
2023: 2692163231175693
Abstract
BACKGROUND: COVID-19 significantly impacted care delivery to seriously ill patients, especially around including family and caregivers in patient care.AIM: Based on routinely collected bereaved family reports, actionable practices were identified to maintain and improve care in the last month of life, with potential application to all seriously ill patients.DESIGN: The Veterans Health Administration's Bereaved Family Survey is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents; the survey includes multiple structured items as well as space for open narrative responses. The responses were analyzed using qualitative content analysis with dual review.SETTING/PARTICIPANTS: Between February 2020 and March 2021, there were 5372 responses to the free response questions of which 1000 (18.6%) responses were randomly selected. The 445 (44.5%) responses from 377 unique individuals included actionable practices.RESULTS: Bereaved family members and caregivers identified four opportunities with a total of 32 actionable practices. Opportunity 1: Facilitate the use of video communication, included four actionable practices. Opportunity 2: Provide timely and accurate responses to family concerns, included 17 actionable practices. Opportunity 3: Accommodate family/caregiver visitation, included eight actionable practices. Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit, included three actionable practices.CONCLUSION: The findings from this quality improvement project are applicable during a pandemic, but also translate to improving the care of seriously ill patients in other circumstances, such as when family members or caregivers are geographically distant from a loved one during the last weeks of life.
View details for DOI 10.1177/02692163231175693
View details for PubMedID 37198879
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Facilitators of palliative care quality improvement team cohesion: Lessons from a seven-site implementation project in India.
Health care management review
2023; 48 (3): 219-228
Abstract
The Palliative Care: Promoting Access and Improvement of the Cancer Experience (PC-PAICE) initiative is a team-based, palliative care (PC) quality improvement (QI) project working to promote high-quality PC in India. As a PC QI initiative, PC-PAICE implementation relied upon building interdisciplinary teams, providing the ideal context for understanding facilitators of team cohesion that compelled clinical, organizational, and administrative team members to work together. There is an opportunity to leverage the intersection between QI implementation and organizational theory to inform and improve implementation science.As a subaim of a larger implementation evaluation, we aimed to identify facilitators of team cohesion within QI implementation context.A quota sampling approach captured the perspectives of 44 stakeholders across three strata (organizational leaders, clinical leaders, and clinical team members) from all seven sites through a semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by organizational theory to identify facilitators.We identified three facilitators of PC team cohesion: (a) balancing formalization and flexibility around team roles, (b) establishing widespread awareness of the QI project, and (c) prioritizing a nonhierarchical organizational culture.Leveraging CFIR to analyze PC-PAICE stakeholder interviews created a data set conducive to understanding complex multisite implementation. Layering role and team theory to our implementation analysis helped us identify facilitators of team cohesion across levels within the team (bounded team), beyond the team (teaming), and surrounding the team (culture). These insights demonstrate the value of team and role theories in implementation evaluation efforts.
View details for DOI 10.1097/HMR.0000000000000368
View details for PubMedID 37158411
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Integrating Patient and Expert Perspectives to Conceptualize High-Quality Palliative Cancer Care for Symptoms in the US Veterans Health Administration: A Qualitative Study.
Inquiry : a journal of medical care organization, provision and financing
2023; 60: 469580231160374
Abstract
Quality measurement is typically the domain of clinical experts and health system leaders; patient/caregiver perspectives are rarely solicited. We aimed to describe and integrate clinician and patient/caregiver conceptualizations of high-quality palliative symptom care for patients receiving care for advanced cancer within the US Veterans Health Administration in the context of existing quality measures. We conducted a secondary qualitative analysis of transcripts from prioritization discussions of process quality measures relevant to cancer palliative care. These discussions occurred during 2 modified RAND-UCLA appropriateness panels: a panel of 10 palliative care clinical expert stakeholders (7 physicians, 2 nurses, 1 social worker) and a panel of 9 patients/caregivers with cancer experience. Discussions were recorded, transcribed, and independently double-coded using an a priori logical framework. Content analysis was used to identify subthemes within codes and axial coding was used to identify crosscutting themes. Patients/caregivers and clinical experts contributed important perspectives to 3 crosscutting themes. First, proactive elicitation of symptoms is critical. Patients/caregivers especially emphasized importance of comprehensive and proactive screening and assessment, especially for pain and mental health. Second, screening and assessment alone is not enough; information elicited from patients must inform care. Measuring screening/assessment and management care processes separately has important limitations. Lastly, high-quality symptom management can be broadly defined if it is patient-centered; high-quality care takes an individualized approach and might include non-medical or non-pharmacological symptom management. Integrating the perspectives of clinical experts and patients/caregivers is critical for health systems to consider as they design and implement quality measures for palliative cancer care.
View details for DOI 10.1177/00469580231160374
View details for PubMedID 36891952
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Racial disparities in inpatient palliative care consultation among frail older patients undergoing high-risk elective surgical procedures in the United States: a cross-sectional study of the national inpatient sample
Health Affairs Scholar
2023
View details for DOI 10.1093/haschl/qxad026
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Sequential and comparative evaluation of pain treatment effectiveness response (SCEPTER), a pragmatic trial for conservative chronic low back pain treatment.
Contemporary clinical trials
2022: 107041
Abstract
Chronic low back pain (cLBP) is a common and highly disabling problem world-wide. Although many treatment options exist, it is unclear how to best sequence the multitude of care options to provide the greatest benefit to patients.The Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER) trial uses a pragmatic, randomized, stepped design. Enrollment targets 2529 participants from 20 Veterans Affairs (VA) medical centers. Participants with chronic low back pain will first be randomized to one of three options: 1) an internet-based self-management program (Pain EASE); 2) a tailored physical therapy program (Enhanced PT); or 3) continued care with active monitoring (CCAM), a form of usual care. Participants not achieving a 30% or 2-point reduction on the study's primary outcome (Brief Pain Inventory Pain Interference (BPI-PI) subscale), 3 months after beginning treatment may undergo re-randomization in a second step to cognitive behavioral therapy for chronic pain, spinal manipulation therapy, or yoga. Secondary outcomes include pain intensity, back pain-related disability, depression, and others. Participants will be assessed every three months until 12 months after initiating their final trial therapy. Companion economic and implementation analyses are also planned.The SCEPTER trial is currently recruiting and enrolling participants.Trial results will inform treatment decisions for the stepped management of chronic low back pain - a common and disabling condition. Additional analyses will help tailor treatment selection to individual patient characteristics, promote efficient resource use, and identify implementation barriers of interventions.clinicaltrials.gov Identifier: NCT04142177.
View details for DOI 10.1016/j.cct.2022.107041
View details for PubMedID 36496154
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Quality Improvement in Itself Changes Your Thinking: Lessons From Disseminating Quality Improvement Methods Through a Multisite International Collaborative Palliative Care Project in India.
JCO global oncology
2022; 8: e2200147
Abstract
PURPOSE: Seven major palliative care (PC) centers in India were mentored through the Palliative Care-Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) by US and Australian academic institutions to implement a quality improvement (QI) project to improve the accessibility and quality of PC at their respective centers. The objective was to evaluate the experiences of teams in implementing QI methods across diverse geographical settings in India.METHODS: A quota sampling approach was used to elicit perspectives of local stakeholders at each site. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Analysis leveraged deductive and inductive approaches.RESULTS: We interviewed 44 participants (eight organizational leaders, 12 clinical leaders, and 24 team members) at seven sites and identified five themes. (1) Implementing QI methods enabled QI teams to think analytically to solve a complex problem and to identify resources. (2) Developing a problem statement by identifying specific gaps in patient care fostered team collaboration toward a common goal. (3) Making use of QI tools (eg, A3 process) systematically provided a new, straightforward QI toolkit and improved QI teams' conceptual understanding. (4) Enhancing stakeholder engagement allowed shared understanding of QI team members' roles and processes and shaped interventions tailored to the local context. (5) Designing less subjective processes for patient care such as assessment scales to identify patient's symptomatic needs positively changed work practices and culture.CONCLUSION: Engaging and empowering multiple stakeholders to use QI methods facilitated the expansion and improvement of PC and cancer services in India. PC-PAICE demonstrated an efficient, effective way to apply QI methods in an international context. The impact of PC-PAICE is being magnified by developing a cadre of Indian QI leaders.
View details for DOI 10.1200/GO.22.00147
View details for PubMedID 36252162
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Using Family Narrative Reports to Identify Practices for Improving End-of-Life Care Quality.
Journal of pain and symptom management
2022
Abstract
Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement.To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care.We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation.Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation.Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.
View details for DOI 10.1016/j.jpainsymman.2022.06.017
View details for PubMedID 35803554
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Considerations for Fostering Palliative Care Awareness in Developing Contexts: Strategies from Locally Initiated Projects in India.
Journal of pain and symptom management
2022
Abstract
Lack of palliative care (PC) awareness is a barrier to its utilization in developing contexts.To identify and understand strategies that changed awareness of the concepts and value of palliative care in a multi-site quality improvement project in India.The Palliative Care - Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) evaluation team conducted 44 semi-structured interviews with clinician and organization stakeholders at seven geographically dispersed sites. We used inductive and deductive approaches in this secondary analysis to identify emerging themes.We identified the following strategies to improve awareness of concepts and value of palliative care. Strategy 1: Educate medical trainees, staff, and the community about palliative care and its concepts. Sub-strategies: Participate in community events. Integrate PC concepts into early medical education. Standardize training for practitioners. Strategy 2: Design and disseminate India-specific research to reinforce awareness of the value of palliative care. Sub-strategies: Publish and use India-specific palliative care research. Strategy 3: Facilitate communication between providers and departments to improve awareness of palliative care services and its concepts. Sub-strategies: Create referral frameworks and network with providers referring to palliative care to change awareness of available services and palliative care concepts.To increase palliative care utilization, program development can include community and provider-focused efforts on awareness of the concepts and value of palliative care. These three strategies held salience across sites representing diverse Indian geographic and cultural settings; as such, they may be applicable to other contexts.
View details for DOI 10.1016/j.jpainsymman.2022.06.011
View details for PubMedID 35764200
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Patient selection strategies in an intensive primary care program.
Healthcare (Amsterdam, Netherlands)
2022; 10 (2): 100627
Abstract
Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context.This study employs an exploratory sequential mixed-methods design. We analyzed qualitative interviews with 21 PIM team and facility leaders and electronic health record (EHR) data from 2,061 patients screened between July 2014 and September 2017 for PIM enrollment. Qualitative data were analyzed using a hybrid inductive/deductive approach. Quantitative data were analyzed using descriptive statistics.Of 1,887 patients identified for PIM services using standardized criteria, over half were deemed inappropriate for PIM services, either because of not having an ambulatory care sensitive condition, living situation, or were already receiving recommended care. Qualitative analysis found that team members considered standardized criteria to be a useful starting point but too broad to be relied on exclusively. Additional data collection through chart review and communication with the current primary care team was needed to adequately assess patient complexity. Qualitative analysis further found that differences in conceptualizing program goals led to conflicting opinions of which patients should be enrolled in PIM.A combined approach that includes clinical judgment, case review, standardized criteria, and targeted program goals are all needed to support appropriate patient selection processes.
View details for DOI 10.1016/j.hjdsi.2022.100627
View details for PubMedID 35421803
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Promising Strategies to Support COVID-19 Vaccination of Healthcare Personnel: Qualitative Insights from the VHA National Implementation.
Journal of general internal medicine
2022
Abstract
BACKGROUND: In August 2021, up to 30% of Americans were uncertain about taking the COVID-19 vaccine, including some healthcare personnel (HCP).OBJECTIVE: Our objective was to identify barriers and facilitators of the Veterans Health Administration (VHA) HCP vaccination program.DESIGN: We conducted key informant interviews with employee occupational health (EOH) providers, using snowball recruitment.PARTICIPANTS: Participants included 43 VHA EOH providers representing 29 of VHA's regionally diverse healthcare systems.APPROACH: Thematic analysis elucidated 5 key themes and specific strategies recommended by EOH.KEY RESULTS: Implementation themes reflected logistics of distribution (supply), addressinganyvaccine concerns orhesitancy (demand), and learning health system strategies/approaches for shared learnings. Specifically, themes included the following: (1) use interdisciplinary task forces to leverage diverse skillsets for vaccine implementation; (2) invest in processes and align resources with priorities, including creating detailed processes, addressing time trade-offs for personnel involved in vaccine clinics by suspending everything non-essential, designating process/authority to shift personnel where needed, and proactively involving leaders to support resource allocation/alignment; (3) expect and accommodate vaccine buy-in occurring over time: prepare for some HCP's slow buy-in, align buy-in facilitation with identities and motivation, and encourage word-of-mouth and hyper-local testimonials; (4) overcome misinformation with trustworthy communication: tailor communication to individuals and address COVID vaccines "in every encounter," leverage proactive institutional messaging to reinforce information, and invite bi-directional conversations about any vaccine concerns. A final overarching theme focused on learning health system needs and structures: (5) use existing and newly developed communication channels to foster shared learning across teams and sites.CONCLUSIONS: Expecting deliberation allows systems to prepare for complex distribution logistics (supply) and make room for conversations that are trustworthy, bi-directional, and identity aligned (demand). Ideally, organizations provide time for conversations that address individual concerns, foster bi-directional shared decision-making, respect HCP beliefs and identities, and emphasize shared identities as healthcare providers.
View details for DOI 10.1007/s11606-022-07439-y
View details for PubMedID 35260957
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Provider perceptions of challenges to identifying women Veterans with hazardous substance use.
BMC health services research
2022; 22 (1): 300
Abstract
Approximately one-third of women Veterans Health Administration (VHA) users have substance use disorders (SUD). Early identification of hazardous substance use in this population is critical for the prevention and treatment of SUD. We aimed to understand challenges to identifying women Veterans with hazardous substance use to improve future referral, evaluation, and treatment efforts.Design: We conducted a secondary analysis of semi-structured interviews conducted with VHA interdisciplinary women's SUD providers at VA Greater Los Angeles Healthcare System.Using purposive and snowball sampling we interviewed 17 VHA providers from psychology, social work, women's health, primary care, and psychiatry.Our analytic approach was content analysis of provider perceptions of identifying hazardous substance use in women Veterans.Providers noted limitations across an array of existing identification methodologies employed to identify women with hazardous substance use and believed these limitations were abated through trusting provider-patient communication. Providers emphasized the need to have a process in place to respond to hazardous use when identified. Provider level factors, including provider bias, and patient level factors such as how they self-identify, may impact identification of women Veterans with hazardous substance use. Tailoring language to be sensitive to patient identity may help with identification in women Veterans with hazardous substance use or SUD who are not getting care in VHA but are eligible as well as those who are not eligible for care in VHA.To overcome limitations of existing screening tools and processes of identifying and referring women Veterans with hazardous substance use to appropriate care, future efforts should focus on minimizing provider bias, building trust in patient-provider relationships, and accommodating patient identities.
View details for DOI 10.1186/s12913-022-07640-z
View details for PubMedID 35246113
View details for PubMedCentralID PMC8895644
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Teaming in Interdisciplinary Chronic Pain Management Interventions in Primary Care: a Systematic Review of Randomized Controlled Trials.
Journal of general internal medicine
2022
Abstract
BACKGROUND: Current pain management recommendations emphasize leveraging interdisciplinary teams. We aimed to identify key features of interdisciplinary team structures and processes associated with improved pain outcomes for patients experiencing chronic pain in primary care settings.METHODS: We searched PubMed, EMBASE, and CINAHL for randomized studies published after 2009. Included studies had to report patient-reported pain outcomes (e.g., BPI total pain, GCPS pain intensity, RMDQ pain-related disability), include primary care as an intervention setting, and demonstrate some evidence of teamwork or teaming; specifically, they needed to involve at least two clinicians interacting with each other and with patients in an ongoing process over at least two timepoints. We assessed study quality with the Cochrane Risk of Bias tool. We narratively synthesized intervention team structures and processes, comparing among interventions that reported a clinically meaningful improvement in patient-reported pain outcomes defined by the minimal clinically important difference (MCID).RESULTS: We included 13 total interventions in our review, of which eight reported a clinically meaningful improvement in at least one patient-reported pain outcome. No included studies had an overall high risk of bias. We identified the role of a care manager as a common structural feature of the interventions with some clinical effect on patient-reported pain. The team processes involving clinicians varied across interventions reporting clinically improved pain outcomes. However, when analyzing team processes involving patients, six of the interventions with some clinical effect on pain relied on pre-scheduled phone calls for continuous patient follow-up.DISCUSSION: Our review suggests that interdisciplinary interventions incorporating teamwork and teaming can improve patient-reported pain outcomes in comparison to usual care. Given the current evidence, future interventions might prioritize care managers and mechanisms for patient follow-up to help bridge the gap between clinical guidelines and the implementation of interdisciplinary, team-based chronic pain care.
View details for DOI 10.1007/s11606-021-07255-w
View details for PubMedID 35239110
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Empowering families to take on a palliative caregiver role for patients with cancer in India: Persistent challenges and promising strategies.
PloS one
2022; 17 (9): e0274770
Abstract
BACKGROUND: The population of patients with cancer requiring palliative care (PC) is on the rise in India. Family caregivers will be essential members of the care team in the provision of PC.OBJECTIVE: We aimed to characterize provider perspectives of the challenges that Indian families face in taking on a palliative caregiving role.METHOD: Data for this analysis came from an evaluation of the PC-PAICE project, a series of quality improvement interventions for PC in India. We conducted 44 in-depth semi-structured interviews with organizational leaders and clinical team members at seven geographically and structurally diverse settings. Through thematic content analysis, themes relating to the caregivers' role were identified using a combination of deductive and inductive approaches.RESULT: Contextual challenges to taking up the PC caregiving role included family members' limited knowledge about PC and cancer, the necessity of training for caregiving responsibilities, and cultural preferences for pursuing curative treatments over palliative ones. Some logistical challenges include financial, time, and mental health limitations that family caregivers may encounter when navigating the expectations of taking on the caregiving role. Strategies to facilitate family buy-in for PC provision include adopting a family care model, connecting them to services provided by Non-Governmental Organizations, leveraging volunteers and social workers to foster PC awareness and training, and responding specifically to family's requests.CONCLUSION: Understanding and addressing the various challenges that families face in adopting the caregiver role are essential steps in the provision and expansion of PC in India. Locally initiated quality improvement projects can be a way to address these challenges based on the context.
View details for DOI 10.1371/journal.pone.0274770
View details for PubMedID 36112593
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Goals of Care Documentation: Insights from A Pilot Implementation Study.
Journal of pain and symptom management
1800
Abstract
CONTEXT: . The Life Sustaining Treatment Decision Initiative is a national effort by the Veterans Health Administration to ensure goals of care documentation occurs among all patients at high risk of life-threatening events.OBJECTIVES: . Examine likelihood to receive goals of care documentation and explore associations between documentation and perceived patient care experience at the individual and site level.METHODS: . Retrospective, quality improvement analysis of initiative pilot data from four geographically diverse Veterans Affairs (VA) sites (Fall 2014-Winter 2016) before national roll-out. Goals of care documentation according to gender, marital status, urban/rural status, race/ethnicity, age, serious health condition, and Care Assessment Needs scores. Association between goals of care documentation and perceived patient care experience analyzed based on Bereaved Family Survey outcomes of overall care, communication, and support.RESULTS: . Veterans were more likely to have goals of care documentation if widowed, urban residents, and of white race. Patients older than 65-years and those with a higher Care Assessment Needs score were twice as likely as a frail patient to have goals of care documented. One pilot site demonstrated a positive association between documentation and perceived support. Pilot site was a statistically significant predictor of the occurrence of goals of care documentation and Bereaved Family Survey scores.CONCLUSION: . Older and seriously ill patients were most likely to have goals of care documented. Association between a documented goals of care conversation and perceived patient care experience were largely unsupported. Site-level largely contributed to understanding the likelihood of documentation and care experience.
View details for DOI 10.1016/j.jpainsymman.2021.12.023
View details for PubMedID 34952172
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Correction to: Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures.
Journal of general internal medicine
2021
View details for DOI 10.1007/s11606-021-07160-2
View details for PubMedID 34731438
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The Implementation and Effectiveness of Battlefield Auricular Acupuncture for Pain.
Pain medicine (Malden, Mass.)
2021; 22 (8): 1721-1726
View details for DOI 10.1093/pm/pnaa474
View details for PubMedID 33769534
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Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach.
Palliative medicine
2021: 2692163211020473
Abstract
BACKGROUND: The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations.AIM: Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative.DESIGN: A qualitative thematic analysis of semi-structured interviews.SETTING/PARTICIPANTS: Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers.RESULTS: Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers.CONCLUSIONS: Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
View details for DOI 10.1177/02692163211020473
View details for PubMedID 34080488
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Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study.
Journal of general internal medicine
2021
Abstract
BACKGROUND: Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers.OBJECTIVES: To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system.DESIGN: Qualitative research.PARTICIPANTS: We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs).APPROACH: We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus.RESULTS: Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines.CONCLUSIONS: Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.
View details for DOI 10.1007/s11606-021-06747-z
View details for PubMedID 33948790
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Opportunities for improving opioid disposal practices in the Veterans Health Administration.
American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists
2021
Abstract
DISCLAIMER: In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PURPOSE: The potentially vast supply of unused opioids in Americans' homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement.METHODS: We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities.RESULTS: While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic.CONCLUSION: A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.
View details for DOI 10.1093/ajhp/zxab163
View details for PubMedID 33851212
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Protecting the healthcare workforce during COVID-19: a qualitative needs assessment of employee occupational health in the US national Veterans Health Administration.
BMJ open
2021; 11 (10): e049134
Abstract
OBJECTIVE: Early in the COVID-19 pandemic, US Veterans Health Administration (VHA) employee occupational health (EOH) providers were tasked with assuming a central role in coordinating employee COVID-19 screening and clearance for duty, representing entirely novel EOH responsibilities. In a rapid qualitative needs assessment, we aimed to identify learnings from the field to support the vastly expanding role of EOH providers in a national healthcare system.METHODS: We employed rapid qualitative analysis of key informant interviews in a maximal variation sample on the parameters of job type, rural versus urban and provider gender. We interviewed 21 VHA EOH providers between July and December 2020. This sample represents 15 facilities from diverse regions of the USA (large, medium and small facilities in the Mid-Atlantic; medium sites in the South; large facilities in the West and Pacific Northwest).RESULTS: Five interdependent needs included: (1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (eg, employee-facing electronic health records and coordinated databases); (2) mechanisms for information sharing across settings (eg, VHA listserv), especially for changing policy and protocols; (3) sufficiently resourced staffing using detailing to align EOH needs with human resource capital; (4) connected and resourced local and national leaders; and (5) strategies to support healthcare worker mental health.Our identified facilitators for EOH assuming new challenging and dynamically changing roles during COVID-19 included: (A) training or access to expertise; (B) existing mechanisms for information sharing; (C) flexible and responsive staffing; and (D) leveraging other institutional expertise not previously affiliated with EOH (eg, chaplains to support bereavement).CONCLUSIONS: Our needs assessment highlights local and system level barriers and facilitators of EOH assuming expanded roles during COVID-19. Integrating changes both within and across systems and with alignment of human capital will enable EOH preparedness for future challenges.
View details for DOI 10.1136/bmjopen-2021-049134
View details for PubMedID 34607860
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How Patients and Providers Weigh the Risks and Benefits of Long-Term Opioid Therapy for Cancer Pain.
JCO oncology practice
2021: OP2000679
Abstract
To understand how patients and providers weigh the risks and benefits of long-term opioid therapy (LTOT) for cancer pain.Researchers used VA approved audio-recording devices to record interviews. ATLAS t.i., a qualitative analysis software, was used for analysis of transcribed interview data. Participants included 20 Veteran patients and 20 interdisciplinary providers from primary care- and oncology-based practice settings. We conducted semistructured interviews and analyzed transcripts used thematic qualitative methods. Interviews explored factors that affect decision making about appropriateness of LTOT for cancer related pain. We saturated themes for providers and patients separately.Factors affecting patient decision-making included influence from various information sources, persuasion from trusted providers, and sometimes deferral of the decision to their provider. Relative prioritization of pain management as the focal patient concern varied with some patients describing comparatively more fear of chemotherapy than opioid analgesics, comparatively more knowledge of opioids in relation to other drugs;patients expressed a preference to spend the limited time they have with their oncologist discussing cancer treatment rather than opioid use. Factors affecting provider decision making included prognosis, patient goals, patient characteristics, and provider experience and biases. Providers differed in how they weigh the relative importance of alleviating pain or avoiding opioids in the face of treating patients with cancer and histories of substance abuse.Divergent perspectives on factors need to be considered when weighing risks and benefits. Policies and interventions should be designed to reduce variation in practice to promote equal access to adequate pain management. Improved shared decision-making initiatives will take advantage of patient decision-making factors and priorities.
View details for DOI 10.1200/OP.20.00679
View details for PubMedID 33534632
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Expert Stakeholder Prioritization of Process Quality Measures to Achieve Patient- and Family-Centered Palliative and End-of-Life Cancer Care.
Journal of palliative medicine
2021
Abstract
Importance: Quality measures of palliative and end-of-life care relevant to patients with advanced cancer have been developed, but few are in routine use. It is unclear which of these measures are most important for providing patient- and family-centered care and have high potential for improving quality of care. Objective: To prioritize process quality measures for assessing delivery of patient- and family-centered palliative and end-of-life cancer care in US Veterans Affairs (VA) health care facilities. Design, Setting, Participants: A panel of 10 palliative and cancer care expert stakeholders (7 physicians, 2 nurses, 1 social worker) rated process quality measure concepts before and after a 1-day meeting. Measures: Panelists rated 64 measure concepts on a nine-point scale on: (1) importance to providing patient- and family-centered care, and (2) potential for quality improvement (QI). Panelists also nominated five highest priority measure concepts ("top 5") on each attribute. Results: Panelists rated most measure concepts (54 premeeting, 56 post-meeting) as highly important to patient- and family-centered care (median rating ≥7). Considerably fewer (17 premeeting, 22 post-meeting) were rated as having high potential for QI. Measure concepts having postpanel median ratings ≥7 and nominated by one or more panelists as "top 5" on either attribute comprised a shortlist of 20 measure concepts. Conclusions: A panel of expert stakeholders helped prioritize 64 measure concepts into a shortlist of 20. Half of the shortlisted measures were related to communication about patient preferences and decision making, and half were related to symptom assessment and treatment.
View details for DOI 10.1089/jpm.2020.0633
View details for PubMedID 33605800
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Barriers and Facilitators of Using Quality Improvement To Foster Locally Initiated Innovation in Palliative Care Services in India.
Journal of general internal medicine
2020
Abstract
BACKGROUND: Quality improvement (QI) methods represent a vehicle for fostering locally initiated innovation cycles. We partnered with palliative care services from seven diverse practice settings in India to foster locally initiated improvement projects.OBJECTIVE: To evaluate the implementation experiences of locally initiated palliative care improvement projects at seven diverse sites and understand the barriers and facilitators of using QI to improve palliative care in India.PARTICIPANTS: We use a quota sampling approach to capture the perspectives of 44 local stakeholders in each of the following three categories (organizational leaders, clinic leaders, and clinical team members) through a semi-structured interview guide informed by the consolidated framework for implementation research (CFIR). We use standard qualitative methods to identify facilitators and barriers to using QI methods in seven diverse palliative care contexts.RESULTS: Across all sites, respondents emphasized the following factors important in the success of quality improvement initiative: leveraging clinic level data, QI methods training, provider buy-in, engaged mentors, committed leadership, team support, interdepartmental coordination, collaborations with other providers, local champions, and having a structure for accountability. Barriers to using QI methods to improve palliative care services included lack of designated staff, high patient volume, resources, patient population geographic constraints, general awareness and acceptance of palliative care, and culture.CONCLUSIONS: Empowering local leaders and medical personnel to champion, design, and iterate using QI methods represents a promising powerful tool to spread palliative care services in developing countries.
View details for DOI 10.1007/s11606-020-06152-y
View details for PubMedID 32901438
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Does Offering Battlefield Acupuncture Lead to Subsequent Use of Traditional Acupuncture?
Medical care
2020; 58 Suppl 2 9S (2 9 Suppl): S108-S115
Abstract
Veterans Health Administration encourages auricular acupuncture (Battlefield Acupuncture/BFA) as a nonpharmacologic approach to pain management. Qualitative reports highlighted a "gateway hypothesis": providing BFA can lead to additional nonpharmacologic treatments. This analysis examines subsequent use of traditional acupuncture.Cohort study of Veterans treated with BFA and a propensity score matched comparison group with a 3-month follow-up period to identify subsequent use of traditional acupuncture. Matching variables included pain, comorbidity, and demographics, with further adjustment in multivariate regression analysis.We identified 41,234 patients who used BFA across 130 Veterans Health Administration medical facilities between October 1, 2016 and March 31, 2019. These patients were matched 2:1 on Veterans who used VA care but not BFA during the same period resulting in a population of 24,037 BFA users and a comparison cohort of 40,358 non-BFA users. Patients with prior use of traditional acupuncture were excluded.Among Veterans receiving BFA, 9.5% subsequently used traditional acupuncture compared with 0.9% of non-BFA users (P<0.001). In adjusted analysis, accounting for patient characteristics and regional availability of traditional acupuncture, patients who used BFA had 10.9 times greater odds (95% confidence interval, 8.67-12.24) of subsequent traditional acupuncture use.Providing BFA, which is easy to administer during a patient visit and does not require providers be formally certified, led to a substantial increase in use of traditional acupuncture. These findings suggest that the value of offering BFA may not only be its immediate potential for pain relief but also subsequent engagement in additional therapies.
View details for DOI 10.1097/MLR.0000000000001367
View details for PubMedID 32826780
View details for PubMedCentralID PMC7497608
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Provider Perspectives of Battlefield Acupuncture: Advantages, Disadvantages and Its Potential Role in Reducing Opioid Use for Pain.
Medical care
2020; 58 Suppl 2 9S (2 9 Suppl): S88-S93
Abstract
Nonpharmacological options to treat pain are in demand, in part to address the opioid crisis. One such option is acupuncture. Battlefield acupuncture (BFA) is an auricular needling protocol currently used to treat pain in the Veterans Health Administration. We aimed to identify the advantages and disadvantages of BFA from providers' perspectives.We rely on an inductive qualitative approach to explore provider perceptions through thematic analysis of semistructured interviews with 43 BFA providers across the nation.We identified the following themes. Disadvantages included: (1) clinical guidelines are insufficient; (2) patients often request multiple BFA visits from providers; (3) BFA can be uncomfortable; (4) BFA may not be an effective treatment option unless it can be provided "on demand"; and (5) BFA can promote euphoria, which can have deleterious consequences for patient self-care. Perceived advantages included: (1) BFA can simultaneously effectively control pain while reducing opioid use; (2) BFA may alleviate the pain that has been unsuccessfully treated by conventional methods; (3) BFA gives providers a treatment option to offer patients with substance use disorder; (4) BFA helps build a trusting patient-provider relationship; (5) BFA can create the opportunity for hope.Providers perceive BFA to have many benefits, both clinical and relational, including ways in which it may have utility in addressing the current opioid crisis. BFA is easy to deliver and has potential clinical and relational utility. Efforts to better understand effectiveness are warranted.
View details for DOI 10.1097/MLR.0000000000001332
View details for PubMedID 32826777
View details for PubMedCentralID PMC7497600
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Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans.
Medical care
2020; 58 Suppl 2 9S (2 9 Suppl): S101-S107
Abstract
Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective.In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information.A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record.More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids.VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.
View details for DOI 10.1097/MLR.0000000000001368
View details for PubMedID 32826779
View details for PubMedCentralID PMC7497594
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Managing Opioids, Including Misuse and Addiction, in Patients With Serious Illness in Ambulatory Palliative Care: A Qualitative Study.
The American journal of hospice & palliative care
2020; 37 (7): 507-513
Abstract
Pain and opioid management are core ambulatory palliative care skills. Existing literature on how to manage opioid misuse/use disorder excludes patients found in palliative care settings, such as individuals with serious illness or those at the end of life.We conducted an exploratory study to: (1) Identify the challenges palliative care clinicians face when prescribing opioids in ambulatory settings and (2) explore factors that affect opioid decision-making.We recruited palliative care clinicians who prescribe opioids in ambulatory settings, which included open-ended questions and was conducted online. Results were analyzed qualitatively using a content analysis-based approach.Eighty-three palliative care clinicians (mostly MDs/DOs) participated. Challenges faced when prescribing opioids included clinician differences in approach to care (eg, transitioning from another clinician with more permissive opioid prescribing), medication access (eg, inadequate pharmacy supply), resource constraints (eg, access to mental health and addiction expertise), managing problems outside the typical palliative care scope (eg addiction). Participants also discussed factors that influenced their opioid prescribing decisions, such as opioid-related harms and risks that they need to weigh; they also spoke about the necessity of considering other factors like the patient's environment, disease, treatment, and prognosis.This study highlights the challenge of opioid management in patients with serious illness, particularly when misuse or substance use disorder is present, and suggests areas for future research focus. Our next step will be to establish consensus on approaches to opioid prescribing decision-making and policy in seriously ill patients presenting to ambulatory palliative care.
View details for DOI 10.1177/1049909119890556
View details for PubMedID 31763926
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Elements of the Healthy Work Environment Associated with Lower Primary Care Nurse Burnout
Nursing Outlook
2019: 14-25
Abstract
Little is known about the relationship between primary care nurses' work environment and burnout, particularly in settings where patient-centered medical homes (PCMH) have been implemented.To investigate the relationship between PCMH nurses' work environment and burnout.Multivariable analyses were performed using two waves of survey data from PCMH registered nurses (RNs; n = 170) and PCMH licensed vocational nurses (LVNs; n = 181) in 23 primary care clinics.True collaboration was inversely associated with PCMH RN burnout (b = -2.6, 95% confidence interval [CI] = -4.29, -0.08, p < .01). Meaningful recognition was inversely associated with PCMH LVN burnout (b = -5.1, 95% CI = -8.36, -1.82, p < .01). In models with all nurses, RN (vs. LVN) position was associated with higher levels of burnout (b = 6.2, 95% CI = 2.47, 9.84, p < .01).This study highlights the important role of the work environment in reducing PCMH nurse burnout. Strategies to foster team collaboration and meaningful recognition should be investigated to reduce PCMH nurse burnout.
View details for DOI 10.1016/j.outlook.2019.06.018
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Elements of the healthy work environment associated with lower primary care nurse burnout.
Nursing outlook
2020; 68 (1): 14-25
Abstract
Little is known about the relationship between primary care nurses' work environment and burnout, particularly in settings where patient-centered medical homes (PCMH) have been implemented.To investigate the relationship between PCMH nurses' work environment and burnout.Multivariable analyses were performed using two waves of survey data from PCMH registered nurses (RNs; n = 170) and PCMH licensed vocational nurses (LVNs; n = 181) in 23 primary care clinics.True collaboration was inversely associated with PCMH RN burnout (b = -2.6, 95% confidence interval [CI] = -4.29, -0.08, p < .01). Meaningful recognition was inversely associated with PCMH LVN burnout (b = -5.1, 95% CI = -8.36, -1.82, p < .01). In models with all nurses, RN (vs. LVN) position was associated with higher levels of burnout (b = 6.2, 95% CI = 2.47, 9.84, p < .01).This study highlights the important role of the work environment in reducing PCMH nurse burnout. Strategies to foster team collaboration and meaningful recognition should be investigated to reduce PCMH nurse burnout.
View details for DOI 10.1016/j.outlook.2019.06.018
View details for PubMedID 31477313
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Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration.
Implementation science : IS
2020; 15 (1): 18
Abstract
Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants' fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity.Nine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010-2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis.Seven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity.This study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.
View details for DOI 10.1186/s13012-020-0979-y
View details for PubMedID 32183873
View details for PubMedCentralID PMC7079486
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Risk of opioid misuse in people with cancer and pain and related clinical considerations: a qualitative study of the perspectives of Australian general practitioners.
BMJ open
2020; 10 (2): e034363
Abstract
OBJECTIVE: To explore the perspectives of general practitioners (GPs) concerning the risk of opioid misuse in people with cancer and pain and related clinical considerations.DESIGN: A qualitative approach using semistructured telephone interviews. Analysis used an integrative approach.SETTING: Primary care.PARTICIPANTS: Australian GPs with experience of prescribing opioids for people with cancer and pain.RESULTS: Twenty-two GPs participated, and three themes emerged. Theme 1 (Misuse is not the main problem) contextualised misuse as a relatively minor concern compared with pain control and toxicity, and highlighted underlying systemic factors, including limitations in continuity of care and doctor expertise. Theme 2 ('A different mindset' for cancer pain) captured participants' relative comfort in prescribing opioids for pain in cancer versus non-cancer contexts, and acknowledgement that compassion and greater perceived community acceptance were driving factors, in addition to scientific support for mechanisms and clinical efficacy. Participant attitudes towards prescribing for people with cancer versus non-cancer pain differed most when cancer was in the palliative phase, when they were unconcerned by misuse. Participants were equivocal about the risk-benefit ratio of long-term opioid therapy in the chronic phase of cancer, and were reluctant to prescribe for disease-free survivors. Theme 3 ('The question is always, 'how lazy have you been?') captured participants' acknowledgement that they sometimes prescribed opioids for cancer pain as a default, easier option compared with more holistic pain management.CONCLUSIONS: Findings highlight the role of specific clinical considerations in distinguishing risk of opioid misuse in the cancer versus non-cancer population, rather than diagnosis per se. Further efforts are needed to ensure continuity of care where opioid prescribing is shared. Greater evidence is needed to guide opioid prescribing in disease-free survivors and the chronic phase of cancer, especially in the context of new treatments for metastatic disease.
View details for DOI 10.1136/bmjopen-2019-034363
View details for PubMedID 32071185
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The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative.
Journal of pain and symptom management
2020
Abstract
Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.
View details for DOI 10.1016/j.jpainsymman.2020.08.025
View details for PubMedID 32858163
View details for PubMedCentralID PMC7445485
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Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer.
JCO oncology practice
2020: OP2000240
Abstract
Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer.We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into "measure concepts" and higher-level groups.Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care-specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1).Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.
View details for DOI 10.1200/OP.20.00240
View details for PubMedID 32758085
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"Asking Is Never Bad, I Would Venture on That": Patients' Perspectives on Routine Pain Screening in VA Primary Care.
Pain medicine (Malden, Mass.)
2020
Abstract
Screening for pain in routine care is one of the efforts that the Veterans Health Administration has adopted in its national pain management strategy. We aimed to understand patients' perspectives and preferences about the experience of being screened for pain in primary care.Semistructured interviews captured patient perceptions and preferences of pain screening, assessment, and management.We completed interviews with 36 patients: 29 males and seven females ranging in age from 28 to 94 years from three geographically distinct VA health care systems.We evaluated transcripts using constant comparison and identified emergent themes.Theme 1: Pain screening can "determine the tone of the examination"; Theme 2: Screening can initiate communication about pain; Theme 3: Screening can facilitate patient recall and reflection; Theme 4: Screening for pain may help identify under-reported psychological pain, mental distress, and suicidality; Theme 5: Patient recommendations about how to improve screening for pain.Our results indicate that patients perceive meaningful, positive impacts of routine pain screening that as yet have not been considered in the literature. Specifically, screening for pain may help capture mental health concerns that may otherwise not emerge.
View details for DOI 10.1093/pm/pnaa016
View details for PubMedID 32142132
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Pilot of the Life-Sustaining Treatment Decisions Initiative Among Veterans With Serious Illness.
The American journal of hospice & palliative care
2020: 1049909120923595
Abstract
Prior to national spread, the Department of Veterans Affairs implemented a pilot of the life-sustaining treatment decisions initiative (LSTDI) to promote proactive goals of care conversations (GoCC) with seriously ill patients, including policy and practice standards, an electronic documentation template and order set, and implementation support.To describe a 2-year pilot of the LSTDI at 4 demonstration sites.Prospective observational study.A total of 6664 patients who had at least one GoCC.Descriptive statistics characterized patient demographics, goals of care, LST decisions, and risk of hospitalization or mortality among patients with at least one GoCC. Participants were on average 71.4 years old, 93.2% male, 87.1% white, and 64.7% urban; 27.3% died by the end of the pilot period. Fifteen percent lacked decision-making capacity (DMC). Nonmutually exclusive goals included to be cured (7.6%), to prolong life (34%), to improve/maintain quality of life (61.5%), to be comfortable (53%), to obtain support for family/caregiver (8.4%), to achieve life goals (2.1%), and other (10.5%). Many GoCCs resulted in a do not resuscitate (DNR) order (58.8%). Patients without DMC were more likely to have comfort-oriented goals (77.3% vs 48.8%) and a DNR (84% vs 52.6%). Chart abstraction supported content validity of GoCC documentation.The pilot demonstrated that standardizing practices for eliciting and documenting GoCCs resulted in customized documentation of goals of care and LST decisions of a large number of seriously ill patients and established the feasibility of spreading standardized practices throughout a large integrated health care system.
View details for DOI 10.1177/1049909120923595
View details for PubMedID 32383388
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Developing Unique Insights from Narrative Responses to Bereaved Family Surveys.
Journal of pain and symptom management
2020
Abstract
Although bereaved family surveys are routinely used quantitatively for quality assessment, open-ended, narrative responses are rarely systematically analyzed. Analysis of narrative responses may identify opportunities for improving end-of-life (EOL) care delivery.To highlight the value of routine, systematic analysis of narrative responses, and to thematically summarize narrative responses to the VA's Bereaved Family Survey.We analyzed over 4600 open-ended responses to the Bereaved Family Survey for all 2017 inpatient decedents across VA facilities. We used a descriptive qualitative approach (9) to identify major themes.Thematic findings clustered into three domains: patient needs, family needs, and facility and organizational characteristics. Patient needs include maintenance of Veteran's hygiene, appropriately prescribing medications, adhering to patient wishes, physical presence in patient's final hours, and spiritual and religious care at EOL. Family and caregiver needs included enhanced communication with the patient's care team, assistance with administrative and logistical challenges after death, emotional support, and displays of respect and gratitude for the patient's life. Facility and organizational characteristics included care team coordination, optimal staffing, the importance of non-clinical staff to care, and optimizing facilities to be welcoming, equipped for individuals with disabilities, and able to provide high quality food.Systematic analysis of narrative survey data yields unique findings not routinely available through quantitative data collection and analysis. Organizations may benefit from the collection and regular analysis of narrative survey responses, which facilitates identification of needed improvements in palliative and EOL care that may improve the overall experiences for patients and families.
View details for DOI 10.1016/j.jpainsymman.2020.05.007
View details for PubMedID 32428664
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Implementing Goals of Care Conversations: Lessons from High and Low Performing Sites from a VA National Initiative.
Journal of pain and symptom management
2020
Abstract
The Veterans Health Administration (VA) National Center for Ethics in Healthcare (NCEHC) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning (ACP) via goals of care conversations for seriously ill Veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.We conducted semi-structured interviews with 31 key stakeholders from 11 sites to identify cross-site best practices and pitfalls related to implementation.Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.Learning healthcare systems need multi-level interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education in order to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.This study of a national implementation of ACP demonstrates that the route to success is variable, with flexible core components of leaders/advisors, champions, and resources that can be instantiated at various levels in a highly complex organization.
View details for DOI 10.1016/j.jpainsymman.2020.07.040
View details for PubMedID 32781166
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"Sometimes you wonder, is this really true?": Clinician assessment of patients' subjective experience of pain.
Journal of evaluation in clinical practice
2019
Abstract
BACKGROUND: Pain is a subjective experience that must be translated by clinicians into an objective assessment to guide intervention.OBJECTIVE: To understand how patients' subjective experience of pain is translated by primary care clinicians into an objective clinical assessment of pain to effectively guide intervention.METHODS: We conducted nine multidisciplinary focus groups with a combined total of 60 Veteran affair (VA) primary care providers and staff from two large VA medical centers in California and Oregon. We used content analysis methods to identify key themes pertaining to clinical assessment of a subjective experience.RESULTS: We present four emergent themes. Theme 1: Pain is a highly individualized and subjective experience not adequately captured by a simple numeric scale; Theme 2: Conflict commonly exists between the patient's reported experience of pain and the clinician's observations and expectations of pain; Theme 3: Providers attempt to recalibrate the patient's reported experience to reflect their own understanding of pain; and Theme 4: Providers perceive that some patients may overreport their pain because they do not know how to standardize their subjective experience.CONCLUSIONS: A persistent challenge to pain assessment and management is how clinicians reconcile a patient's subjective self-reported experience with their own clinical assessment and personal biases. Future work should explore these themes from the patient perspective.
View details for DOI 10.1111/jep.13298
View details for PubMedID 31680385
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Signature Informed Consent for Long-Term Opioid Therapy in Patients with Cancer: Perspectives of Patients and Providers.
Journal of pain and symptom management
2019
Abstract
CONTEXT: Signature informed consent (SIC) is a part of a Veterans Health Administration (VHA) ethics initiative for patient education and shared decision-making with long-term opioid therapy (LTOT). Historically, patients with cancer-related pain receiving LTOT are exempt from this process.OBJECTIVES: Our objective is to understand patients' and providers' perspectives on using signature informed consent for LTOT in patients with cancer-related pain.METHODS: Semi-structured interviews with 20 opioid prescribers and 20 patients who were prescribed opioids at two large academically-affiliated VHA Medical Centers. We employed a combination of deductive and inductive approaches in content analysis to produce emergent themes.RESULTS: Potential advantages of SIC are that it can clarify and help patients comprehend LTOT risks and benefits, provide clear upfront boundaries and expectations, and involve the patient in shared decision-making. Potential disadvantages of SIC include time delay to treatment, discouragement from recommended opioid use, and impaired trust in the patient-provider relationship. Providers and patients have misconceptions about the definition of SIC. Providers and patients question if SIC for LTOT is really informed consent. Providers and patients advocate for strategies to improve comprehension of SIC content. Providers had divergent perspectives on exemptions from SIC. Oncologists want SIC for LTOT to be tailored for patients with cancer.CONCLUSION: Provider and patient interviews highlight various aspects about the advantages and disadvantages of requiring SIC for LTOT in cancer-related pain. Tailoring SIC for LTOT to be specific to cancer related concerns and to have an appropriate literacy level are important considerations.
View details for DOI 10.1016/j.jpainsymman.2019.08.020
View details for PubMedID 31476361
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Teaching primary care teamwork: a conceptual model of primary care team performance.
The clinical teacher
2019
View details for DOI 10.1111/tct.13037
View details for PubMedID 31282077
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How middle managers facilitate interdisciplinary primary care team functioning
HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION
2019; 7 (2): 10–15
View details for DOI 10.1016/j.hjdsi.2018.11.003
View details for Web of Science ID 000471956900005
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Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain.
Pain medicine (Malden, Mass.)
2019
Abstract
Pain and opioid use are highly prevalent, leading for calls to include nonpharmacological options in pain management, including complementary and integrative health (CIH) therapies. More than 2,000 randomized controlled trials (RCTs) and many systematic reviews have been conducted on CIH therapies, making it difficult to easily understand what type of CIH therapy might be effective for what type of pain. Here we synthesize the strength of the evidence for four types of CIH therapies on pain: acupuncture, therapeutic massage, mindfulness techniques, and tai chi.We conducted searches of English-language systematic reviews and RCTs in 11 electronic databases and previously published reviews for each type of CIH. To synthesize that large body of literature, we then created an "evidence map," or a visual display, of the literature size and broad estimates of effectiveness for pain.Many systematic reviews met our inclusion criteria: acupuncture (86), massage (38), mindfulness techniques (11), and tai chi (21). The evidence for acupuncture was strongest, and largest for headache and chronic pain. Mindfulness, massage, and tai chi have statistically significant positive effects on some types of pain. However, firm conclusions cannot be drawn for many types of pain due to methodological limitations or lack of RCTs.There is sufficient strength of evidence for acupuncture for various types of pain. Individual studies indicate that tai chi, mindfulness, and massage may be promising for multiple types of chronic pain. Additional sufficiently powered RCTs are warranted to indicate tai chi, mindfulness, and massage for other types of pain.
View details for DOI 10.1093/pm/pnz068
View details for PubMedID 31070752
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What makes team communication effective: a qualitative analysis of interprofessional primary care team members' perspectives.
Journal of interprofessional care
2019: 1-3
Abstract
Although numerous scholars have emphasized the need for effective communication between members of interprofessional teams, few studies provide a clear understanding of what constitutes effective team communication in primary care settings, specifically where patient-centered medical home (PCMH) teams have been implemented. This paper describes the elements of effective communication as perceived by members of interprofessional PCMH primary care teams, and identifies elements of effective communication that have persisted over time. Using transcribed text from 75 semi-structured interviews, we applied the grounded theory method of constant comparison to categorize emergent themes relating to elements of team communication. Interprofessional PCMH team members described the elements of effective communication as: 1) shared knowledge, 2) situation/goal awareness, 3) problem-solving, 4) mutual respect; and communication that is 5) transparent, 6) timely, 7) frequent, 8) consistent, and 9) parsimonious. Parsimony is an emergent theme that may be especially relevant for interprofessional PCMH teams challenged with structured clinic schedules. Future work could focus on understanding how to teach and sustain effective parsimonious communication. Comprehensive quality improvement efforts incorporating a variety of strategies, including team communication training, information and communication technologies, and standardized communication tools may facilitate communication of pertinent patient information in a brief and concise manner.
View details for DOI 10.1080/13561820.2019.1577809
View details for PubMedID 30724679
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What Do Providers Want from a Pain Screening Measure Used in Daily Practice?
PAIN MEDICINE
2019; 20 (1): 68–76
Abstract
We aimed to understand providers' experiences and preferences regarding several brief pain screening measures.We collected two waves of data for this analysis. Wave one: We conducted nine focus groups with multidisciplinary Department of Veterans Affairs (VA) providers. Wave two: To understand an emergent theme in wave one, we conducted 15 telephone interviews with prescribing providers where we used a semistructured guide comparing screening measures currently used in VA practices. Using content analysis of the wave two interviews, we evaluated providers' perceptions of important aspects of brief pain screening measures and reported emergent themes.Five emergent themes underlie providers' perceptions of the utility of brief pain screening measures: 1) item abstractness: how bounded and concrete a patient's interpretation of an individual item is; 2) item distinctness: belief in the patient's ability to differentiate between the meaning of various items in a pain measure; 3) item anchoring: presence of a description under each response option making the meaning explicit; 4) item look-back period: the period of time over which patients are asked to remember and comment on their pain; 5) parsimony: identifying the shortest and simplest approach possible to acquire desired information.Overly complex or adaptive screening tools may include information that is ultimately not used by providers. Conversely, overly simplistic pain screening tools may omit information that helps providers understand the impact of pain on patients' lives. As pain is nuanced, complex, and subjective, all screening measures exhibit some limitations. No single pain measure serves all chronic pain patients, and specific contexts or settings may warrant additional specific items.
View details for PubMedID 30085285
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Interprofessional training and team function in patient-centred medical home: Findings from a mixed method study of interdisciplinary provider perspectives
JOURNAL OF INTERPROFESSIONAL CARE
2018; 32 (6): 735–44
Abstract
Transitioning from profession-specific to interprofessional (IP) models of care requires major change. The Veterans Assessment and Improvement Laboratory (VAIL), is an initiative based in the United States that supports and evaluates the Veterans Health Administration's (VAs) transition of its primary care practices to an IP team based patient-centred medical home (PCMH) care model. We postulated that modifiable primary care practice organizational climate factors impact PCMH implementation. VAIL administered a survey to 322 IP team members in primary care practices in one VA administrative region during early implementation of the PCMH and interviewed 79 representative team members. We used convergent mixed methods to study modifiable organizational climate factors in relationship to IP team functioning. We found that leadership support and job satisfaction were significantly positively associated with team functioning. We saw no association between team functioning and either role readiness or team training. Qualitative interview data confirmed survey findings and explained why the association with IP team training might be absent. In conclusion, our findings demonstrate the importance of leadership support and individual job satisfaction in producing highly functioning PCMH teams. Based on qualitative findings, we hypothesize interprofessional training is important, however, inconsistencies in IP training delivery compromise its potential benefit. Future implementation efforts should improve standardization of training process and train team members together. Interprofessional leadership coordination of interprofessional training is warranted.
View details for DOI 10.1080/13561820.2018.1509844
View details for Web of Science ID 000456939800009
View details for PubMedID 30156933
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Veteran Experiences Seeking Non-pharmacologic Approaches for Pain
MILITARY MEDICINE
2018; 183 (11-12): E628–E634
Abstract
Pain is a longstanding and growing concern among US military veterans. Although many individuals rely on medications, a growing body of literature supports the use of complementary non-pharmacologic approaches when treating pain. Our objective is to characterize veteran experiences with and barriers to accessing alternatives to medication (e.g., non-pharmacologic treatments or non-pharmacologic approaches) for pain in primary care.Data for this qualitative analysis were collected as part of the Effective Screening for Pain (ESP) study (2012-2017), a national randomized controlled trial of pain screening and assessment methods. This study was approved by the Veterans Affairs (VA) Central IRB and veteran participants signed written informed consent. We recruited a convenience sample of US military veterans in four primary care clinics and conducted semi-structured interviews (25-65 min) elucidating veteran experiences with assessment and management of pain in VA Healthcare Systems. We completed interviews with 36 veterans, including 7 females and 29 males, from three VA health care systems. They ranged in age from 28 to 94 yr and had pain intensity ratings ranging from 0 to 9 on the "pain now" numeric rating scale at the time of the interviews. We analyzed interview transcripts using constant comparison and produced mutually agreed upon themes.Veteran experiences with and barriers to accessing complementary non-pharmacologic approaches for pain clustered into five main themes: communication with provider about complementary approaches ("one of the best things the VA has ever given me was pain education and it was through my occupational therapist"), care coordination ("I have friends that go to small clinic in [area A] and I still see them down in [facility in area B] and they're going through headaches upon headaches in trying to get their information to their primary care docs"), veteran expectations about pain experience ("I think as a society we have shifted the focus to if this doctor doesn't relieve me of my pain I will find someone who does"), veteran knowledge and beliefs about various complementary non-pharmacologic approaches ("how many people know that tai chi will help with pain?… Probably none. I saw them doing tai chi down here at the VA clinic and the only reason I knew about it was because I saw it being done"), and access ("the only physical therapy I ever did… it helped…but it was a two-and-a-half-hour drive to get there three times a week… I can't do this"). Specific access barriers included local availability, time, distance, scheduling flexibility, enrollment, and reimbursement.The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.
View details for PubMedID 29590422
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Challenges and Strategies for Implementing Battlefield Acupuncture in the Veterans Administration: A Qualitative Study of Provider Perspectives
MEDICAL ACUPUNCTURE
2018; 30 (5): 252–61
Abstract
Objective: Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges. Materials and Methods: Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide. Results: Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues. Conclusions: System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention.
View details for DOI 10.1089/acu.2018.1286
View details for Web of Science ID 000447308700010
View details for PubMedID 30377461
View details for PubMedCentralID PMC6205764
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Patient-Centered Pain Management Communication from the Patient Perspective
JOURNAL OF GENERAL INTERNAL MEDICINE
2018; 33 (8): 1374–80
View details for DOI 10.1007/s11606-018-4490-y
View details for Web of Science ID 000440608100033
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Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid management.
BMC family practice
2018; 19 (1): 107
Abstract
BACKGROUND: Facilitating appropriate and safe prescribing of opioid medications for chronic pain management in primary care is a pressing public health concern. Interdisciplinary team-based models of primary care are exploring the expansion of clinical pharmacist roles to support disease management for chronic conditions, e.g. pain. Our study aims to 1) identify roles clinical pharmacists can assume in primary care team based chronic pain care processes and 2) understand the barriers to assuming these expanded roles.METHODS: Setting: Veterans Health Administration (VA) has implemented an interdisciplinary team-based model for primary care which includes clinical pharmacists.DESIGN: We employed an inductive two part qualitative approach including focus groups and semi-structured interviews with key informants.PARTICIPANTS: 60 members of VA primary care teams in two states participated in nine preliminary interdisciplinary focus groups where a semi-structured interview guide elucidated provider experiences with screening for and managing chronic pain. To follow up on emergent themes relating to clinical pharmacist roles, an additional 14 primary care providers and clinical pharmacists were interviewed individually. We evaluated focus group and interview transcripts using the method of constant comparison and produced mutually agreed upon themes.RESULTS: Clinical pharmacists were identified by primary care providers as playing a central role with the ongoing management of opioid therapy including review of the state prescription drug monitoring program, managing laboratory screening, providing medication education, promoting naloxone use, and opioid tapering. Specific barriers to clinical pharmacists role expansion around pain care include: limitations of scopes of practice, insufficient institutional support (low staffing, dedicated time, insufficient training, lack of interdisciplinary leadership support), and challenges and opportunities for disseminating clinical pharmacists' expanded roles.CONCLUSIONS: Expanding the role of the clinical pharmacist to collaborate with providers around primary care based chronic pain management is a promising strategy for improving pain management on an interdisciplinary primary care team. However, expanded roles have to be balanced with competing responsibilities relating to other conditions. Interdisciplinary leadership is needed to facilitate training, resources, adequate staffing, as well as to prepare both clinical pharmacists and the providers they support, about expanded clinical pharmacists' scopes of practice and capabilities.
View details for PubMedID 29970008
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Barriers to Using Nonpharmacologic Approaches and Reducing Opioid Use in Primary Care
PAIN MEDICINE
2018; 19 (7): 1357–64
Abstract
Opioid prescribing for chronic pain, including the potential for over-reliance and misuse, is a public health concern.In the context of Veterans Administration (VA) primary care team-based pain management, we aimed to understand providers' perceptions of barriers to reducing opioid use and improving the use of nonpharmacologic pain management therapies (NPTs) for chronic pain.A semistructured interview elucidated provider experiences with assessing and managing pain. Emergent themes were mapped to known dimensions of VA primary care access.Informants included 60 primary care providers, registered nurses, licensed practical nurses, clerks, psychologists, and social workers at two VA Medical Centers.Nine multidisciplinary focus groups.Provider perceptions of barriers to reducing opioids and improving use of NPTs for patients with chronic pain clustered around availability and access. Barriers to NPT access included the following subthemes: geographical (patient distance from service), financial (out-of-pocket cost to patient), temporal (treatment time delays), cultural (belief that NPTs increased provider workload, perception of insufficient training on NPTs, perceptions of patient resistance to change, confrontation avoidance, and insufficient leadership support), and digital (measure used for pain assessment, older patients hesitant to use technology, providers overwhelmed by information).Decreasing reliance on opioids for chronic pain requires a commitment to local availability and provider-facing strategies that increase efficacy in prescribing NPTs. Policies and interventions for decreasing utilization of opioids and increasing use of NPTs should comprehensively consider access barriers.
View details for PubMedID 29059412
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"It Encourages Them to Complain": A Qualitative Study of the Unintended Consequences of Assessing Patient-Reported Pain
JOURNAL OF PAIN
2018; 19 (5): 562–68
Abstract
The "Pain as the 5th Vital Sign" initiative intended to address undertreatment of pain by encouraging routine pain assessment and management. In the Veterans Health Administration, routine pain screening has been practiced in primary care for more than a decade, but has not improved the quality of pain management measured using several process indicators, and some have expressed concerns of potentially fostering undesirable use of prescription opioids. We sought to evaluate the consequences of routine pain screening on clinical practice. We conducted 9 interdisciplinary focus groups with 60 primary care providers and staff from 5 outpatient Veterans Health Administration clinics. We identified 5 themes reflecting 1 intended and 4 unintended consequences of routine pain screening: it 1) facilitates identification of patients with pain who might otherwise be overlooked, 2) may need to be targeted toward specific patients and contexts rather than universally applied, 3) often shifts visit focus away from more emergent concerns, 4) may encourage "false positives" and prompt providers to intervene when treatment is not a priority, and 5) engenders a "pain problem" and hinders patients from considering alternative strategies. These findings suggest changes to support patient-centered pain assessment and improve targeted screening and interventions for population pain management.This article describes some of the potential unintended consequences of implementing routine pain screening in primary care. This information may help clinicians be more strategic in their consideration and use of pain screening among their patients.
View details for PubMedID 29421247
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Challenges to teaming for pain in primary care
HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION
2018; 6 (1): 23–27
View details for PubMedID 28711504
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What Patients and Providers Want to Know About Complementary and Integrative Health Therapies
JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
2018; 24 (1): 85–89
Abstract
We conducted a quality improvement project to determine (1) what information providers and patients most wanted to learn about complementary and integrative health (CIH) therapies and (2) in what format they wanted to receive this information. The overall aim was to develop educational materials to facilitate the CIH therapy decision-making processes.We used mixed methods to iteratively pilot test and revise provider and patient educational materials on yoga and meditation. We conducted semistructured interviews with 11 medical providers and held seven focus groups and used feedback forms with 52 outpatients. We iteratively developed and tested three versions of both provider and patient materials. Activities were conducted at four Veterans Administration medical facilities (two large medical centers and two outpatient clinics).Patients want educational materials with clearly stated basic information about: (1) what mindfulness and yoga are, (2) what a yoga/meditation class entails and how classes can be modified to suit different abilities, (3) key benefits to health and wellness, and (4) how to find classes at the hospital/clinic. Diverse media (videos, handouts, pocket guides) appealed to different Veterans. Videos should depict patients speaking to patients and demonstrating the CIH therapy. Written materials should be one to three pages with colors, and images and messages targeting a variety of patients. Providers wanted a concise (one-page) sheet in black and white font with no images listing the scientific evidence for CIH therapies from high-impact journals, organized by either type of CIH or health condition to use during patient encounters, and including practical information about how to refer patients.Providers and patients want to learn more about CIH therapies, but want the information in succinct, targeted formats. The information learned and materials developed in this study can be used by others to educate patients and providers on CIH therapies.
View details for DOI 10.1089/acm.2017.0074
View details for Web of Science ID 000422937900013
View details for PubMedID 28749702
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Role expansion on interprofessional primary care teams: Barriers of role self-efficacy among clinical associates
HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION
2016; 4 (4): 321–26
Abstract
Interprofessional team-based models of primary care that expand the role of clinical associates (CAs) are increasingly adopted in primary care practices. In this study we query team members of a newly implemented patient centered medical home (PCMH) to identify facilitators and barriers of occupational role self-efficacy, a belief of possessing the capacity to execute their new team based role effectively.79 key informants, members of primary care teams at six Veterans Health Administration (VA) clinics, were interviewed to assess their experiences with implementing expanded roles for CAs. All sites had implemented Patient Aligned Care Teams, the VA's version of PCMH.Three themes that produced the self-efficacy necessary for successful role expansion of CAs were identified: (1) role training (2) time and resources for roles and (3) cross-disciplinary role agreement. Sub-themes emerged around role challenges. Training sub themes included incomplete or limited training, inconsistencies in trainings within a site, and not receiving training with team members. Insufficient resources sub-themes included limited time for expanded tasks, inadequate space, low staffing, and poor task mix. Cross-disciplinary agreement failed to occur specifically when there was insufficient coordination between medicine and nursing leadership about staff roles, poor primary care provider (PCPs) knowledge of the boundaries of staff roles, and lack of synchronicity between staff roles and what PCPs would like staff roles to include.These identified themes have implications for healthcare professionals working in interprofessional teams in a variety of settings and indicate the need for interdisciplinary leadership based solutions.Clarifying the factors that impact self-efficacy for the role expansion of PACT staff can inform strategies for role transformation for enhanced primary care delivery.
View details for DOI 10.1016/j.hjdsi.2016.03.004
View details for Web of Science ID 000390918300016
View details for PubMedID 28007226
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Teamlet Structure and Early Experiences of Medical Home Implementation for Veterans
JOURNAL OF GENERAL INTERNAL MEDICINE
2014; 29: 623–31
Abstract
High functioning interdisciplinary primary care teams are a critical component of the patient-centered medical home. In 2010, the Veterans Administration (VA) implemented a medical home model termed the Patient Aligned Care Teams (PACT), with reorganization of staff into small teams ("teamlets") as a core feature.To examine the early experiences of primary care personnel as they assumed new roles through reorganization into teamlets.Convergent mixed methods study design involving semi-structured interviews and a survey; data were collected in 2011 and 2012.We interviewed 41 frontline teamlet members (i.e., primary care physicians and staff) from three practices that were part of a PACT demonstration laboratory and examined clinician and staff survey data from 22 practices.Semi-structured interview guide and clinician and staff survey questions covering the following domains: teamlet formation and structure, within-teamlet communication, cross-coverage, role changes, teamlet training, impact on Veterans, and leadership facilitation and support.Respondents had limited input into teamlet structure and indicated limited training on the PACT initiative. Guidelines delineating each teamlet member's roles and responsibilities were emphasized as important needs. Chronic understaffing also contributed to implementation challenges and territorial attitudes surfaced when cross-coverage was not clear. In addition, several core features of VA's medical home transformation were not fully implemented by teamlet members. Most also reported limited guidance and feedback from leadership. Despite these challenges, teamlet-based care was perceived to have a positive impact on Veterans' experiences of primary care and also resulted in improved communication among staff.The PACT teamlet model holds much promise for improving primary care at the VA. However, more comprehensive training, improving the stability of teamlets, developing clear cross-coverage policies, and better defined teamlet member responsibilities are important areas in need of attention by VA leadership.
View details for DOI 10.1007/s11606-013-2680-1
View details for Web of Science ID 000338334700012
View details for PubMedID 24715392
View details for PubMedCentralID PMC4070242