Among Veterans in VHA care, musculoskeletal disorders (MSD), including back conditions and osteoarthritis, are highly prevalent, often painful, and costly. Yet, little is known about the characteristics of Veterans with MSD, the development and persistence of pain, variation in pain management, associated medical and mental health conditions, and treatments outcomes and costs. The MSD Cohort was created in order to examine these characteristics across demographic groups, geographic regions, and facilities. These data can help identify gaps in care which inform quality improvement efforts. This project plays a key role in the development of VHA pain management performance measures.
We identified Veterans with MSD and described their socio-demographic and clinical characteristics; variation in pain screening, severity and persistence; duration and recurrence of MSD episodes; 2) assessed treatment and outcomes variation, including disparities and time to treatment, by patient and facility characteristics; effect of mental health services on pain reports; aberrant medication behaviors (e.g., early opioid refills) and adverse events associated with long term opioid therapy (OT); and 3) estimated costs of MSD care. Theoretically and empirically informed hypotheses will examine the role of moderators of care, costs, and outcomes, especially pain severity, gender, and comorbidities. The project provided data to directly support the strategic plan of the National Pain Management Program Office and our other partners.
We created a longitudinal cohort of Veterans with MSD in VHA care from national VHA electronic clinical and administrative data in order to examine variation in pain, pain treatment, comorbidities, and outcomes, by patient and facility characteristics. The MSD cohort served as a foundational Clinical Information System to inform efforts to promote Delivery Systems and Health System Organizational Change consistent with ongoing VHA transformational efforts to encourage Veteran-centered care. The cohort was designed to inform other CREATE projects by providing algorithms to facilitate use of VHA electronic data to identify health services utilization, comorbid conditions, receipt of opioid medications, and pain screening results, over time.
Over 50% (N=5.2 million) of Veterans who received VHA care between 2000 and 2014 had one or more MSD diagnosis. Women Veterans constituted an increasing proportion of MSD patients (e.g. 6% in 2001 vs. 8.5% in 2014). More recently diagnosed Veterans reported higher pain scores, with nearly 50% reporting moderate to severe pain, and they were more likely to have multiple concurrent MSD , depressive disorder diagnoses, and PTSD. Veterans with housing instability and MSD were more likely to report high levels of pain, have high rates of medical and mental health comorbid conditions, but less likely to receive an opioid medication. Black Veterans diagnosed with osteoarthritis were less likely to undergo joint replacement than white Veterans: in contrast, Hispanics and whites received TKA at similar rates, and these differences remained relatively stable over time.
This study identified needs for integrated pain, mental health and medical care across a range of comorbid conditions. We identified facility-level variation in pain treatment processes and use of risky pain treatments and determined the impact of this variation on pain trajectories. Additionally, we provided information on the effect of long term opioid therapy on the course of pain and outcomes such as new depressive disorder diagnoses. This information will guide VHA Clinical Operations in their efforts to reduce variation in care access and process quality across VHA. This study is particularly timely and policy relevant since the VA has expanded the Opioid Safety Initiative (OSI) nationally in FY 2013. The OSI aims to reduce over-reliance on opioid analgesics for pain management and to promote safe and effective use of opioid therapy when clinically indicated.
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Grant Number: I01HX000971-01
None at this time.