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

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

3. Proportion of VA Patients with Comorbid Chronic Pain

4. Chronic Pain as a Competing Demand in Outpatient Care

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

6. To fully satisfy the USPSTF recommendations, 1,773 hours of a physician’s annual time, or 7.4 hours per working day is needed in the provision of preventive services. Yarnall KS, Pollak KI, Ostbye T, et al. Primary care: Is there enough time for prevention? AJPH 2003;93:645-641.

7. The Effect of Chronic Pain on Diabetes Patients’ Self-Management Krein SL, Heisler M, Piette JD, et al. The effect of chronic pain on diabetes patients’ self-management. Diabetes Care 2005;28:65-70.

8. Self-Rated Health P <.001

9. Diabetes Self-Management Problems Chronic Pain (n = 557) No Chronic Pain (n = 371) P-value Rx Problem8%4%.01 Activity Problem73%43%<.001 Dietary Problem54%37%<.001 Footcare Problem15%9%.01 Monitoring Problem19%15%.13

10. Medication Adherence and Medication Costs

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

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

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

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

15. Strategies for Intervention

16. Clinicians should play a consistent and realistic role in a larger system that brings together partners, information technology, and community resources. Attention will increasingly turn to the responsibility of managers of healthcare systems to build the infrastructure to make that happen. (Stange et al. AJPM 2002).

17. Collaboration with support of the UM FGP, UMHS, VA HSR&D, BCBSF, and other organizations Leadership includes researchers, administrators, and clinicians throughout UMHS Goal is to develop novel, relevant strategies for improving chronic illness care at UM and beyond

18. Using the RE-AIM framework to set priorities Moving beyond a one-size-fits-all approach to a portfolio of strategies that meet the needs of a diverse patient pool Augmenting clinicians’ reach while keeping care coordination within their team

19. Technology-Assisted Peer Support Telephone case management programs require nursing resources that many health systems lack Peer support may help, but patients may have concerned about privacy Many patients lack the initiative or organization to ensure that contacts are made regularly From a health system perspective, telephone peer support initiatives are difficult to integrate with other care management services

20. How Does It Work?

21. A Pilot Study

22. Quote from Diabetes Pilot Study “A lot of old people like us sit around at home and look out the window. We feel sick and pretty useless. I learned things I could be doing to take care of myself from [my peer partner]. But I also felt that I helped him. I enjoyed talking to him on the phone, and it made me feel inspired to do more.” (Heisler M, Piette JD, Diab Educ, 2005)

23. Supporting Informal Care Providers Many patients need frequent support with problems that go below the health system’s radar Growing numbers of patients live alone Informal care providers lack the skills or structure to be effective in assisting with self- care

24. How Does It Work?

25. In Conclusion Chronic pain is a serious, often ignored problem in traditional health systems. Pain can have pervasive effects on chronically-ill patients clinical care and self-management. There are real limits on what can be done to address these issues within the context of traditional, face-to-face outpatient visits. There are things we can do to improving the care of patients with pain. Strengthening between-visit support and bolstering informal systems of care could help.

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

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

29. An Ongoing RCT To evaluate the effect of group visits + IVR-facilitated peer support on diabetes patients’ glycemic control and insulin use; To assess the impact of the intervention on key patient-centered outcomes To identify patient characteristics associated with willingness to participate in the intervention and mediators of the intervention’s impact on patient outcomes

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

31. Descriptive Statistics Chronic Pain (n = 557) No Chronic Pain (n = 371) P-value Mean Age6466<.001 % insulin4436.01 % Men9699.008 % White6771.16 Mean BMI31.529.5<.001 % High School+8381.53

32. Regression Results: Self-management Score Beta95% CIP Chronic Pain-5.0-7.8 to -2.2.002 CES-D  10 -6.6-8.9 to -4.3.000 Health fair/poor-3.7-6.2 to -1.1.008 1 Pain.72-.87 to 2.3.350  2 comorbidities -1.5-3.5 to.41.110 DM not priority-4.9-8.1 to -1.8.004 Adjusting for income, education, insulin, age, sex, race, BMI and clustering by site

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

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

35. Low Trust (N=332)High Trust (N=533) %P-value% Rx Cost $1-$504.2<.001 $51-$10012.1 >$10029.6 Income $25K+ $15K - $24K $10 - $14K < $10K Prevalence of Cost-Related Medication Underuse within Subgroups of VA Diabetes Patients Defined by Physician Trust From: Piette, Heisler, Krein, and Kerr. Arch Int Med, 2005.

36. Low Trust (N=332)High Trust (N=533) %P-value% Rx Cost $1-$504.2<.0013.6.01 $51-$10012.16.6 >$10029.611.0 Income $25K+ $15K - $24K $10 - $14K < $10K Prevalence of Cost-Related Medication Underuse within Subgroups of VA Diabetes Patients Defined by Physician Trust From: Piette, Heisler, Krein, and Kerr. Arch Int Med, in press.

37. Low Trust (N=332)High Trust (N=533) %P-value% Rx Cost $1-$504.2<.0013.6.01 $51-$10012.16.6 >$10029.611.0 Income $25K+8.2.04 $15K - $24K7.1 $10 - $14K17.7 < $10K18.2 Prevalence of Cost-Related Medication Underuse within Subgroups of VA Diabetes Patients Defined by Physician Trust From: Piette, Heisler, Krein, and Kerr. Arch Int Med, in press.

38. Low Trust (N=332)High Trust (N=533) %P-value% Rx Cost $1-$504.2<.0013.6.01 $51-$10012.16.6 >$10029.611.0 Income $25K+8.2.045.9.6 $15K - $24K7.17.7 $10 - $14K17.74.3 < $10K18.24.2 Prevalence of Cost-Related Medication Underuse within Subgroups of VA Diabetes Patients Defined by Physician Trust From: Piette, Heisler, Krein, and Kerr. Arch Int Med, in press.