Incorporating Patient and Provider Voices into the Veterans Pain Care Organizational Improvement Comparative Effectiveness Study: Informing Future Implementation.

Abstract

Background: Clinicians and healthcare systems have little evidence available to guide effective strategies to manage pain while reducing opioid use. The Veterans Pain Care Organizational Improvement Comparative Effectiveness (VOICE) trial tested two strategies to manage pain and reduce opioid use in primary care settings: interdisciplinary pain team (IPT) and pharmacist collaborative management (PCM).

Objectives: This qualitative process evaluation was conducted parallel to the effectiveness trial to inform future implementation efforts.

Design: Ethnographic observations and semi-structured interviews.

Participants: Study staff (n=19), facility clinicians (n=37), facility clinical champions (n=4), and patients (n=32) from 10 Veterans Health Administration (VHA) facilities.

Approach: Guided by the Practical Implementation Sustainability Model (PRISM), we used rapid analysis procedures to identify and categorize themes relevant to implementation. Key themes were identified for the PRISM constructs of implementation and sustainability infrastructure, organizational characteristics, organizational perspectives of the interventions, patient perspectives of the interventions, patient characteristics, and the external environment. To facilitate the development of recommendations for successful and sustainable implementation, identified themes were also mapped to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) outcomes, which are part of the PRISM framework.

Key results: Successful adoption required leadership support and scanning the environment for existing similar programs and interested, knowledgeable clinical champions. Implementation was supported by training in core features of the interventions, which included meaningful patient involvement in decision-making, responsiveness of the clinical team, and the longevity and intensity of the interventions. Maintenance was supported through sustained leadership support for dedicated clinical team positions and standardized roles and procedures.

Conclusion: This process evaluation identified strategies to support the successful implementation and sustainment of both interventions. Implementation considerations are particularly important as sites determine which intervention(s) to adopt, given that the VOICE trial found the interventions to be similarly effective at improving pain and reducing opioid dosage.