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Volume 40 Number 5, September/October 2003
Pages ix — xi

Guest Editorial

Clinical research as a foundation for Veterans Health Administration Pain Management Strategy


Early this year, the Editor of Journal of the American Medical Association (JAMA) put out a call for "Pain Management" papers to be published in a special thematic issue in November 2003 [1]. Specifically, she wrote "The management of pain is a continuing public health problem. Pain of all descriptions is one of the most frequently encountered complaints in physicians' offices, hospitals, chronic care facilities, and nursing homes. Virtually all health care professionals encounter patients with pain, whether it is acute or chronic; is due to trauma, surgery, arthritis, cancer, or other illnesses; or occurs as part of daily life or at the end of life." Researchers involved with the VHA have longed worked on pain and pain management issues, and we feel the readership of the Journal of Rehabilitation Research and Development (JRRD) would be greatly interested in understanding the current approaches and programs now in use and being developed that address these issues for veterans. Therefore, we have put together this special section to highlight the research and development of pain management within the Department of Veterans Affairs (VA) as a complement to the very exciting JAMA thematic issue.

Photo of Robert D. Kerns, PhD

Robert D. Kerns, PhD
VA Connecticut Healthcare System and Yale University, Clinical Research, as a foundation for the Veterans Health Administration (VHA) Pain Management Strategy

In late 1998, the Veterans Health Administration (VHA) launched a National Pain Management Strategy designed "to develop a comprehensive, multicultural, integrated, systemwide approach to pain management that reduces pain and suffering for veterans experiencing acute and chronic pain associated with a wide range of illnesses, including terminal illness" [2,3]. Early in the implementation of the Strategy, a multidisciplinary VHA National Pain Management Strategy Coordinating Committee (NPMCC) was organized to oversee the development and implementation of the Strategy. Supporting the NPMCC are 21 regional or Veterans Integrated Service Networks (VISNs) points of contact, VISN pain management committees, and local facility pain management oversight committees, in addition to dedicated providers and administrators throughout the VHA.

Over the past 5 years, the NPMCC and many collaborating VHA and non-VHA experts have been responsible for numerous efforts targeting several more specific goals of the Strategy. These goals include the development of a single systemwide standard of care that reduces suffering from pain, development of standards and methods for routine pain assessment of all veterans receiving care in VHA facilities, development and implementation of empirically supported and expert guidelines for promoting state-of-the-art pain care, provision of opportunities for patient and family as well as provider education regarding pain management, development of resources to promote the interdisciplinary management of pain, and the implementation of methods for monitoring performance of the VHA and its facilities in meeting these goals. In the relatively short time since the implementation of the Strategy, substantial progress has been made toward each of these goals. Several publications provide detailed reviews of the VHA National Pain Management Strategy, its organization and implementation processes, and its accomplishments [4,5].

Among the numerous accomplishments of the VHA Pain Management Strategy, several deserve to be highlighted. Since the implementation of the Strategy, systematically collected data document that virtually all veterans who receive care in a primary care or related ambulatory setting are screened for the presence and intensity of pain. Data additionally document that most veterans with at least a moderate level of pain receive a comprehensive pain assessment, have a documented plan of pain care, and receive appropriate and timely reassessment of their response to the intervention. These data are important in documenting improvements in the consistency with which the VHA is approaching pain management and are critical in encouraging ongoing performance improvement activities.

A pain management guidelines working group has collaborated with representatives from the Department of Defense in developing and distributing guidelines and associated resource materials regarding the management of low back pain, acute postoperative pain, and chronic opioid therapy. A pharmacy working group has produced a Web-based learning tool for the pharmaceutical management of pain. A "pain as the 5th vital sign" working group developed a comprehensive manual for conducting routine pain screenings and more comprehensive pain assessments. An outcomes working group has developed a tool kit to assist clinicians and administrators develop a systematic approach for the assessment of outcomes as well as an electronic clinical reminder template for the documentation of pain assessment and interventions.

Provider education and development of strategies for assuring provider competency in pain assessment and management have been particularly important targets of the VHA initiative. Three national VHA faculty leadership conferences on pain management and end-of-life care have been attended by over 1,000 VHA providers from multiple disciplines and from virtually all the VHA facilities and types of clinical settings. Several national satellite broadcasts have provided an overview of the VHA pain management strategy as well as special topics, such as multidisciplinary approaches to pain management, management of coprevalent chronic pain and mental health and substance abuse problems, acute postoperative pain management, and chronic opioid therapy, among others. Monthly teleconferences and an active electronic mail group serve a substantial role in addressing the broadest array of clinical issues facing providers and institutions as they work collaboratively to promote improvements in pain management throughout the VHA facilities.

A particularly exciting project involving collaboration between the VHA and the Institute for Healthcare Improvement was funded to specifically "jump-start" efforts to promote significant pain-relevant performance improvement activities across the VHA and its varied clinical settings. Over a 9-month period, 71 teams representing each of the VISNs acted aggressively to promote improvements in pain screening and assessment, documentation of pain plans of care, and provider and patient education. A systematic process involving the development of quantified goals for improvement and rigorous methods for data collection, monitoring, and analysis was employed. Support for these efforts also came from three national educational conferences, monthly teleconferences, a Web site for posting data and materials for sharing among collaborative participants, and an active electronic mail group. Results revealed relative success related to each of the specified goals. Moderate or severe pain on study units dropped from 24 to 17 percent, pain assessment increased from 75 to 85 percent, pain care plans for patients with at least mild pain increased from 58 to 78 percent, and the number of patients provided with pain educational materials increased from 35 to 62 percent. A paper reporting on the results of this important performance improvement effort is now in publication [6].

An important component of the VHA National Pain Management Strategy is a systematic effort to enhance VHA's ongoing research program in pain management. Each of the VHA research programs, namely the Medical, Health Services, and Rehabilitation Research and Development Programs, as well as the Cooperative Studies Program that supports large-scale, multisite efficacy and effectiveness studies have been engaged in this promotional effort. For example, the Health Services Research and Development Program has identified pain-relevant research as a priority area and numerous "Requests for Proposals" for investigator-initiated projects have been published. These initiatives serve as a substantial acknowledgement of the VHA Office of Research and Development's (ORD's) commitment to promoting the advancement of the scientific basis of clinical pain management in support of VHA's broader Pain Management Strategy.

In this context, this special issue of the JRRD includes three original research articles that represent important areas of concern related to pain management in the VHA. One paper that my colleagues and I coauthored documents the high prevalence of pain complaints among veterans receiving care in a VHA primary care setting and important associations among complaints of pain, self-rated health, health risk behaviors such as tobacco and alcohol use, emotional distress, and use of healthcare resources. Our data generally support the VHA Pain Strategy and the Strategy's calls for routine screening for pain, conducting comprehensive pain assessments, and developing aggressive efforts to reduce unnecessary pain. A second paper by Clark and his colleagues describes the development of a new self-report instrument for the comprehensive assessment of key pain outcomes domains. Important strengths of this instrument include its comprehensive nature, its strong psychometric properties, the fact that it was designed specifically as a pain treatment outcomes measure for use in veteran healthcare settings, and its psychometrics that were evaluate from data collected from veterans receiving care in VHA settings. The availability of the instrument may encourage future research designed to systematically evaluate outcomes associated with pain management efforts in VHA settings. A third paper by Otis and his colleagues offers a comprehensive and critical review of the literature on chronic pain and comorbid post-traumatic stress disorder (PTSD). These authors identify several key questions that should stimulate future research in this area of particular concern to the VHA.

Ultimately, this special series of the JRRD offers a window into the scope of VHA's National Pain Management Strategy and highlights the nature and quality of clinical research supported by VHA's ORD. Hopefully too, this series will spark increased interest in this particularly challenging and important area of clinical investigation and will lead to the development of novel research initiatives. Finally, this special series acknowledges VHA's appreciation of the importance of high-quality clinical research as a critical foundation upon which efforts to promote improved methods for the management of pain should be informed.

Robert D. Kerns, PhD
REFERENCES
1. De Angelis CD. Pain management: a call for papers. JAMA 2002 Nov 6;288(17):2174.
2. Veterans Health Administration. VHA National Pain Management Strategy. Washington (DC): Department of Veterans Affairs; 1998.
3. Veterans Health Administration. VHA Directive 2003-021: Pain management. Washington (DC): Department of Veterans Affairs; 2003.
4. Craine M, Kerns RD, Tollett J. Pain management in the Veterans Health Administration: Development and implementation of pain management improvement strategies in a national healthcare system. APS Bulletin. In press 2003.
5. Kerns R. Improving pain management in the VA. Chatham (NJ): Federal Practitioner; 2001 August supplement. p. 18-25.
6. Cleeland CS, Reyes-Gibby CC, Schall M, Nolan K, Paice J, Rosenberg JM, Tollett, JH, Kerns RD. Rapid improvement in pain management: The Veterans Health Administration and the Institute for Healthcare Improvement Collaborative. Clin J Pain 2003;19(5):298-305.
DOI: 10.1682/JRRD.2003.09.0009

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