Lindsey Dorflinger

Providers' roles in enhancing patients' adherence to pain self management.

ABSTRACTPractice guidelines and empirical research related to pain management encourage clinicians to take active roles in providing education about self management and promoting adoption of a self-management approach. The purpose of the study was to review the relevant literature, summarize aspects of the patient–provider interaction that influence patient engagement in self management for chronic pain, and outline practice recommendations in this area. Review of the literature on aspects of the patient–provider interaction that promote engagement in pain self-management was used. Findings are synthesized into recommendations for providers. Patients benefit from a biopsychosocial and patient-centered approach. Patients are more likely to fully disclose when providers respond empathically, which can improve conceptualization and treatment. Patient education and motivation play important roles in engaging patients in self management. Self management is influenced in part by the patient–provider communication process. Suggestions for communication strategies to facilitate patient engagement in self-management techniques, including empathic discussion of barriers and motivation enhancement, are provided.

Binge eating behavior among a national sample of overweight and obese veterans

Despite the high prevalence of overweight and obesity in the US military veterans, binge eating has not been examined in this population.

Psychosocial factors associated with binge eating among overweight and obese male veterans

The studys primary objective is to compare psychosocial characteristics of overweight/obese male Veterans who report binge eating with those who do not report binge eating. Participants include 111 overweight/obese male Veterans who completed questionnaires assessing binge eating, depression, stress, body image, self-efficacy for healthy eating and physical activity, and barriers to physical activity. Of the study sample, 25.2% are classified as binge eaters. Binge eating status is not significantly associated with age, race/ethnicity, weight, or BMI. Binge eating is associated with higher scores on measures of depression, barriers to exercise, self-classified weight, and lower self-efficacy for both healthy eating and exercise, but is not associated with body satisfaction or recent stress. Findings suggest that a sizable minority of overweight/obese male Veterans engage in binge eating. Depressive symptoms, self-efficacy, and perceived barriers all significantly predicted binge eating. These findings have implications both for identification of overweight/obese men at risk for binge eating disorder as well as for weight loss treatment in the Veteran population.

Barriers and facilitators to use of non-pharmacological treatments in chronic pain

BackgroundConsensus guidelines recommend multi-modal chronic pain treatment with increased uptake of non-pharmacological pain treatment modalities (NPMs). We aimed to identify the barriers and facilitators to uptake of evidence-based NPMs from the perspectives of patients, nurses and primary care providers (PCPs).MethodsWe convened eight separate groups and engaged each in a Nominal Group Technique (NGT) in which participants: (1) created an individual list of barriers (and, in a subsequent round, facilitators) to uptake of NPMs; (2) compiled a group list from the individual lists; and (3) anonymously voted on the top three most important barriers and facilitators. In a separate process, research staff reviewed each group’s responses and categorized them based on staff consensus.ResultsOverall, 26 patients (14 women) with chronic pain participated; their mean age was 55. Overall, 14 nurses and 12 PCPs participated. Seven healthcare professionals were men and 19 were women; the mean age was 45. We categorized barriers and facilitators as related to access, patient-provider interaction, treatment beliefs and support. Top-ranked patient-reported barriers included high cost, transportation problems and low motivation, while top-ranked facilitators included availability of a wider array of NPMs and a team-based approach that included follow-up. Top-ranked provider-reported barriers included inability to promote NPMs once opioid therapy was started and patient skepticism about efficacy of NPMs, while top-ranked facilitators included promotion of a facility-wide treatment philosophy and increased patient knowledge about risks and benefits of NPMs.ConclusionsIn a multi-stakeholder qualitative study using NGT, we found a diverse array of potentially modifiable barriers and facilitators to NPM uptake that may serve as important targets for program development.

Integrating Interdisciplinary Pain Management into Primary Care: Development and Implementation of a Novel Clinical Program

OBJECTIVES The aims of this study were to develop and implement an interdisciplinary pain program integrated in primary care to address stakeholder-identified gaps. DESIGN Program development and evaluation project utilizing a Plan-Do-Study-Act (PDSA) approach to address the identified problem of insufficient pain management resources within primary care. SETTING A large Healthcare System within the Veterans Health Administration, consisting of two academically affiliated medical centers and six community-based outpatients clinics. METHODS An interprofessional group of stakeholders participated in a Rapid Process Improvement Workshop (RPIW), a consensus-building process to identify systems-level gaps and feasible solutions and obtain buy-in. Changes were implemented in 2012, and in a 1-year follow-up, we examined indicators of engagement in specialty and multimodal pain care services as well as patient and provider satisfaction. RESULTS In response to identified barriers, RPIW participants proposed and outlined two readily implementable, interdisciplinary clinics embedded within primary care: 1) the Integrated Pain Clinic, providing in-depth assessment and triage to targeted resources; and 2) the Opioid Reassessment Clinic, providing assessment and structured monitoring of patients with evidence of safety, efficacy, or misuse problems with opioids. Implementation of these programs led to higher rates of engagement in specialty and multimodal pain care services; patients and providers reported satisfaction with these services. CONCLUSIONS Our PDSA cycle engaged an interprofessional group of stakeholders that recommended introduction of new systems-based interventions to better integrate pain resources into primary care to address reported barriers. Early data suggest improved outcomes; examination of additional outcomes is planned.

Psychometric properties of a MOVE!23 subscale: Perceived Contributors to Weight Change in a national sample of veterans.

The MOVE!23, a questionnaire to assess weight-related domains in veterans, was examined. Factor analysis of Perceived Contributors to Weight Change revealed three factors (psychosocial, eating behavior, and medical) that were positively correlated with body mass index, and psychiatric and medical comorbidity (p’s < 0.001). Multivariable cumulative logit models modeling the factor scores indicated that women were more likely than men to endorse psychosocial (odds ratio = 2.15, confidence interval = 2.04–2.27) and medical (odds ratio = 1.69, confidence interval = 1.59–1.79) items. The MOVE!23 Perceived Contributors to Weight Change subscale is a reliable and valid measure that is associated with body mass index and may assist in tailoring treatments according to gender and comorbidity.

A brief screening measure for binge eating in primary care

OBJECTIVE Binge eating disorder (BED) is associated with medical and psychiatric issues commonly seen and managed in primary care; however, the disorder typically goes undetected as there are no assessment tools feasible for use in primary care. The objective was to examine the validity of the VA Binge Eating Screener (VA-BES), a single-item screening measure for binge eating. METHOD The sample consisted of 116 veterans referred to a primary care-based weight management program. Participants had a mean age of 61.66years (SD=8.73) and average BMI of 37.90 (SD=7.35). Frequency of binge eating ranged from zero to 21 episodes per week. The prevalence of BED was 7.76%. All participants completed the Questionnaire of Eating and Weight Patterns - Revised (QEWP-R) to assess for BED. They also completed the VA-BES, and measures of disordered eating and depressive symptoms. RESULTS The VA-BES was compared to the QEWP-R to determine the sensitivity, specificity, positive predictive value, and negative predictive value for each cutpoint. Analyses revealed one cutpoint (≥2 binge eating episodes per week) maximized these values, demonstrated excellent agreement with the QEWP-R (χ2=24.79, p<0.001), and had significant associations with other variables commonly associated with binge eating. DISCUSSION This study demonstrates the utility and validity of a single-item measure to screen for binge eating in primary care. The item can quickly and easily identify binge eating, thus facilitating referral to treatment and potentially subsequent improvements in related medical and mental health comorbidities treated in primary care.

Development and application of an electronic health record information extraction tool to assess quality of pain management in primary care

ABSTRACTChronic pain is one of the most common presenting problems in primary care. Standards and guidelines have been developed for managing chronic pain, but it is unclear whether primary care providers routinely engage in guideline-concordant care. The purpose of this study is to develop a tool for extracting information about the quality of pain care in the primary care setting. Quality indicators were developed through review of the literature, input from an interdisciplinary panel of pain experts, and pilot testing. A comprehensive coding manual was developed, and inter-rater reliability was established. The final tool consists of 12 dichotomously scored indicators assessing quality and documentation of pain care in three domains: assessment, treatment, and reassessment. Presence of indicators varied widely. The tool is reliable and can be utilized to gather valuable information about pain management in the primary care setting.

Binge abstinence is associated with reduced energy intake after treatment in patients with binge eating disorder and obesity

Binge eating disorder (BED) is strongly associated with obesity and related medical and psychiatric morbidities. Cognitive behavioral therapy (CBT) has consistently been shown to reduce binge eating frequency and improve psychological functioning, as well as to produce abstinence rates of roughly 50%. This study examined the relationship between binge abstinence and dietary and psychological outcomes after CBT for BED.

Stepped care model of pain management and quality of pain care in long-term opioid therapy.

Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.