The Integrative Pain Management Program: A Pilot Clinic Serving High-Risk Primary Care Patients with Chronic Pain IM4US CONFERENCE 25 AUGUST 2017 EMILY HURSTAK, MD, MPH, MAS SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
Financial Disclosures! Dr. Hurstak receive funding from the California Healthcare Foundation for her work on a report on non-opioid alternatives for pain management in safety-net clinical settings.! I have no other financial disclosures
Objectives! Describe the implementation of a group-based clinical pilot! Describe an evaluation strategy for an integrative medicine clinical program! Review qualitative & quantitative data on the impact of the clinical pilot on participants & staff! Discuss the process for scaling up & sustaining an integrative approach to chronic pain
Integrative Pain Management Program (IPMP)! Problem: Primary care clinics have limited access to multimodal pain treatments to improve patients pain & function & minimize reliance on opioid analgesics
Integrative Pain Management Program IPMP Goals 1. Improve patient access to integrative treatments for pain 2. Improve patients functional status & quality of life 3. Improve staff & patient experience with chronic pain management
IPMP Design Weekly HOME GROUP Meetings Group-Based Acupuncture Massage & Movement Therapies & Weekly One-on-One Acupuncture Massage Pharmacy Education Health Coaching 12 wks Graduation! Invitation to IPMP Graduates Group
IPMP Pilot! Target population! Primary care patients with chronic pain (> 3mos) on opioids who receive care at an urban safety net clinic! 3 successive cohorts delivered from Feb 2016-Nov 2016! Evaluation Design! Quasi-experimental, wait-list cross-over design
IPMP Evaluation! Objective 1: Determine patient & provider utilization & acceptability of program " Provider Referrals " Participant Attendance " Participant Experience
IPMP Referrals Patient referrals to IPMP (n=145) (all primary care providers referred at least 1 patient) 41% 13% 19% Ineligible (not a TWUHC pt or not on opioids) (19) Not reachable (27) Declined after 1st contact (8) 22% 5% Ultimately declined or subsequently could not be reached (32) Participants (59)
IPMP Attendance! 65% of patients attended > 75% of Home Group sessions! Weekly Home Group Participation (average % attendance per wk)! Cohort 1: 73% (13 avg participants per session)! Cohort 2: 59% (9-10 avg participants per session)! Cohort 3: 49% (7-8 avg participants per session)! Majority of participants attended at least one of each type of session
Participant Experience: Satisfaction! Satisfaction Rates on Survey: Scale of 1 (completely unsatisfied) to 4 (completely satisfied).
Participant Experience: Selected Quotes! Meditation / Mindfulness Practices! I practice the deep breathing every evening when I get home from a busy, sometimes frustrating day. The calming effect is so complete. The abdominal/core muscular focus while inhaling I use for low impact exercise to strengthen my core muscles to help my back.! Zachary showed us how to step away from the pain in a way, to go other places with your brain. I used to experience pain a lot worse than I do now. Now I have more skills, coping mechanisms [for pain].
Participant Experience: Selected Quotes! Medication Education / Naloxone! I now have naloxone in my purse to carry around with me for just in case.! Self Management Skills! I felt the greatest impact of the program was the self massage technique. There were so many beneficial aspects of the program, it s hard to prioritize just one
Patient Focus Group Themes! Group Experience A Sense of Community & Reduced Isolation I learned as much from the other people in my group as I did from the experts or specialists. It feels so good just to know that someone out there actually knows my name, that they actually care to speak to me. The best feeling is when I walk into the group and everyone says Hi -----! I see people now on the street and they know my name! The group helped me [to] open up much more than I would have otherwise. [It] helped me to share what s going on with me - how I am suffering. The group setting creates a safe & supportive environment made up of other people who understand what life with chronic pain is like.
Patient Focus Group Themes! Constructive Feedback! 12 weeks is too short! Now what? My pain problem isn t solved.! Program needs a session on how pain impacts mental health.! Location was hard for participants trying to stay away from drugs/alcohol. Participants reported being offered pain pills in front of clinic.! More acupuncture & massage availability for 1:1 sessions.
IPMP Evaluation: Research Component! Objective 2: Assess short-term pain outcomes " Compare pre/post intervention changes among participants who attended at least one home group " Compare changes in participant outcomes with changes observed among a control group " Control group = waitlisted individuals & research-only participants " Assess whether changes were sustained at 6-month follow up
IPMP Research Participants (N=48)! Mean Age 55.5 (SD = 8.2), Age range 36-69 years! Sex! 22 Female, 23 Male! 1 MTF Transgender, 1 FTM Transgender, 1 participant identified as Gender Queer! Race/Ethnicity! 21 (48.8%) White or Caucasian! 9 (20.9%) African American! 4 (9.3%) Native American! 9 (19.9%)Asian or Other! 7 (14.6%) Latino
IPMP Evaluation: Validated Pain & Function Scales! PROMIS NIH-validated pain scales! Scores Standardized for US population (mean t score=50)! Measures include: " Pain intensity & interference " Anxiety, depression, fatigue, physical functioning, sleep, social satisfaction, & global health! Other validated scales:! Pain catastrophizing scale! Fear avoidance beliefs questionnaire! Chronic pain self efficacy scale
Scales without Statistically Significant Change Observed Cognitive Mediators" Baseline" 3-month" Pre/Post Mean Difference (95% CI)*" Fear avoidance" 21.2" 20.6" -0.58 (-2.79, 1.62)" Pain catastrophization" 30.8" 29.1" -1.70 (-5.12, 1.70)" PROMIS**" Depression" 60.0" 57.9" -2.06 (-4.64, 0.53)" Fatigue" 61.8" 60.1" -1.70 (-4.60, 1.20)" Physical functioning " 35.3" 35.7" 0.35 (-1.59, 2.30)" Sleep disturbance" 51.3" 49.3" -2.06 (-5.09, 0.97)" Higher score more optimal for physical functioning **Minimal clinically important difference varies by measure but very rough threshold = 3 points
Statistically Significant Changes in Pain Outcomes PROMIS** Baseline" 3-month" Pre/Post Mean Difference (95% CI)*" Pain on average" 6.7" 5.9" -0.77 (-1.32, -0.23)" Pain at its least" 4.4" 3.5" -0.81 (-1.50, -0.11)" Pain at its worst" 8.9" 8.1" -0.77 (-1.50, -0.05)" Pain interference (PROMIS***)" 67.5" 65.0" -2.49 (-4.79, -0.19)" Pain self efficacy " 21.9" 28.0" 6.06 (1.87, 10.26)" Higher score more optimal for pain self efficacy **Minimal clinically important difference = 1 but varies by pain severity ***Minimal clinically important difference varies by measure but very rough threshold = 3 points
Change in Pain Intensity: IPMP (n=43) vs. Control Group (n=18) Least Pain Average Pain Worst Pain 3 4 5 6 7 5 6 7 8 7.5 8 8.5 9 9.5 10 0 1 2 time 0 1 2 time 0 1 2 time control treatment control treatment control treatment
Change in Pain Self Efficacy: IPMP (n=43) vs. Control (n=18) Adjusted Predictions of trt#time with 95% CIs Linear Prediction, Fixed Portion 20 25 30 35 40 0 1 2 time control treatment
Statistically Significant Changes in Psychosocial Outcomes (PROMIS**) Baseline" 3-month" Pre/Post Mean Difference (95% CI)*" Anxiety " 62.9" 59.7" -3.21 (-6.16, -0.27)" Global Mental Health" 35.4" 38.2" 2.80 (0.65, 4.95)" Global Physical Health" 35.1" 36.8" 1.70 (0.08, 3.31)" Social satisfaction" 37.5" 40.6" 3.15 (0.41, 5.89)" Lower score more optimal for anxiety *Analysis based on t-tests of IPMP participants who attended at least one home group & completed baseline & 3-month follow up surveys (n=31) **Minimal clinically important difference varies by measure but very rough threshold = 3 points
Change in Global Health: IPMP (n=43) vs. Control (n=18) Global Mental Health Global Physical Health Linear Prediction, Fixed Portion 30 35 40 45 Linear Prediction, Fixed Portion 32 34 36 38 40 0 1 2 time 0 1 2 time control treatment control treatment
IPMP Evaluation: Staff Experience! Objective 3: Assess preliminary effects of program on staff " Stress/frustration/successes with chronic pain " Satisfaction with treatment options " Success referring to/success of different treatments " Confidence in ability to refer/engage patients in IPMP " Burnout using single question Maslach burnout inventory scale
Staff Survey: Baseline (pre IPMP)! Job categories (N=32, 1 missing)! PCPs: 8! RN or Medical Assistant: 11! Social Worker or Psychiatrist: 2! Health Worker, Eligibility Staff, Clerk: 10! Working with patients who have chronic pain is:! Moderately to very stressful! Moderately frustrating! Rate Level of Burnout on a Scale of 1-5: Mean Score 2.5 (SD 1.0)! 2 = Occasionally I am under stress, and I don t always have as much energy as I once did, but I don t feel burned out.! 3 = I am definitely burning out and have one or more symptoms of burnout, such as physical or emotional exhaustion.
Access & Confidence in Different Types of Treatment (pre IPMP)! Satisfaction with Treatment Options Mean Score 1.4 (1=dissatisfied, 2=neutral)! Ease of Referral to Different Options: Limited Access to Non-Medication treatments (acupuncture, massage, mindfulness, nutrition)! How much do you think this treatment will help patients? * (1=not at all, 2=only a little, 3=some, 4=a great deal)! Acupuncture: 3.2 (0.79)! Massage: 3.1 (0.94)! Mindfulness or Meditation: 3.3 (0.75)! Physical Movement: 3.0 (0.69)! Nutrition: 2.6 (1.1)! Education: 2.9 (0.7)
Staff Satisfaction (post IPMP)! Satisfaction with options for pain treatment: 2.7 (0.98)! Consistent with range of neutral to satisfied with options! Statistically significant improvement (1.4 vs. 2.7, p<0.001)! Satisfaction with IPMP: Satisfied to Very Satisfied 3.2 (0.95)! Impacted by patient feedback & having more treatment options for chronic pain! Impression of patient experience with IPMP: Satisfied 3.1 (0.76)! Rate IPMP s effectiveness in: Range of neutral (2) to effective (3)! Improving functioning of patients: 2.9 (0.75)! Reducing opioid misuse: 2.5 (0.69)! Minimizing opioids in treatment: 2.4 (0.78)
Comparison of Stress, Frustration, & Burnout! No statistically significant change in stress, frustration, or burnout level related to caring for patients with chronic pain! Stress range 2.25 (0.84) vs. 2.17 (0.99), p=0.4! Frustration range 2.19 (0.97) vs. 1.70 (1.01), p=0.05! No difference in mean burnout score (2.6 vs. 2.4, p=0.4)
Lessons Learned So Far! An integrative pain management program delivered within a safety-net primary care clinic:! Is feasible & acceptable to patients & providers! Produced high rates of participation & satisfaction! Achieved improvements in pain & psychosocial outcomes for participants
IPMP Future Plans Current IPMP Program Open to ALL patients with pain at TWUHC & another community clinic Home group includes cognitive behavioral therapy & is 16 wks duration IPMP Team includes social worker & behavioral assistants Coming Attractions Expansion to 2 nd clinical hub Development of simplified ongoing evaluation measures
Discussion! Impressions?! Additional questions?! What s next?
Supplementary Slides
IPMP Design Staff Funding DPH Program coordinator In kind: Lead physician Health educator Medical Assistant Physician acupuncturist Pharmacist Contract Acupuncturists Massage therapists Movement instructor Mindfulness instructor DPH general fund SF Health Plan quality improvement incentives Community Partnership Award with UCSF Osher Center Students/volunteers Health coaches Assistants
IPMP Research Participants (N=48)! Housing Status:! Single Room Occupancy Unit: 17 (35.4%)! Rental Housing Unit: 25 (52.1%)! Transitional Housing: 1 (2.1%)! Homeless: 1 (2.1%)! Other Housing Status: 4 (8.3%)! Education! Less than High School Education: 8 (16.7%)! High School or GED: 25 (27.1%)! Some College: 20 (41.7%)! College Graduate or More: 7 (14.6%)
IPMP Research Participants (N=48)! Employment! Full or Part-Time Work 1 (2.1%)! Unemployed 3 (6.3%)! Disabled 38 (79.2%)! Other [student, retired] 6 (12.5%)! Income < 35,000 per year: 48 (100%)! Relationship Status! Single 28 (58.3%)! In a Relationship 5 (10.4%)! Married or Living with a Partner 5 (10.4%)! Divorced, Separated, or Widowed 8 (16.7%)
IPMP Evaluation: Qualitative Interviews Overall Impact of IPMP! Nothing I could think of what it s done to help me. No difference, I was still in pain.! For the first time I ve had real hope that I can manage the pain. I ve had moments of real happiness and contentment, which I hadn t had in years. I m less stressed thinking about dealing with the pain, I m less stressed about self-worth - like I m feeling like I can plug in more to my community now with volunteering, starting to get back into artistic stuff, some writing Really making changes with daily routine of stretching, exercising, meditation, that s really helped a lot with my outlook and my depression has gone down. That s the biggest, that s where it s really helped me a lot is all the anxiety and physical stress surrounding pain like holding my muscles, clenching them.
Remaining Areas of Evaluation! Qualitative Interviews Transcribed 1:1 Interviews! Review & qualitatively code transcripts for themes! Participant Chart Review Trends in Opioid Dose & Medical Comorbidities! Possible Additional Areas of Evaluation! Contact individuals who declined to participate or dropped out & conduct brief survey & qualitative interviews to explore barriers to participation! Plan to explore whether level of program participation correlates with outcomes