2023 HSR&D/QUERI National Conference

1198 — Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity: Results from the COOPERATE Trial

Lead/Presenter: Marianne Matthias,  COIN - Indianapolis
All Authors: Matthias MS (Center for Health Information and Communication, Indianapolis), Burgess, DJ (Center for Care Delivery and Outcomes Research, Minneapolis VA) Daggy, J (Indiana University Department of Biostatistics) Perkins, AJ (Indiana University Department of Biostatistics) Eliacin, J (Center for Health Information and Communication, Indianapolis VA) Hirsh, AT (Department of Psychology, IUPUI) Rand, KL (Department of Psychology, IUPUI) Salyers, MP (Department of Psychology, IUPUI) Myers, LJ (Center for Health Information and Communication, Indianapolis VA) Bair, MJ (Center for Health Information and Communication, Indianapolis VA)

Chronic pain affects up to 70% of Veterans and is a leading cause of disability. Racial disparities in pain treatment have been extensively documented in and out of VA. Moreover, Black patients exhibit lower levels of patient activation—having the knowledge, confidence, and skills to manage one’s health—than White patients. Lower patient activation leads to less effective communication in healthcare settings, including lower likelihood of sharing concerns, asking questions, and preparing for clinic visits, all of which can adversely affect pain management.

COOPERATE is a randomized trial of an intervention to increase patient activation and improve communication for Black Veterans with chronic pain. COOPERATE consists of 6 individual coaching sessions delivered via phone over 3 months, focusing on two essential skill sets to facilitate patient activation: 1) goal setting/prioritization and 2) communication skills. 250 Black Veterans were randomized to the intervention or to attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain intensity and interference, and psychological functioning. Outcomes were assessed at baseline, 3 months (primary endpoint), 6, and 9 months (sustained effects). A linear mixed-model repeated measures approach was used to test change in the primary outcome, patient activation, compared to the control group at 3 months. Group differences in change from baseline at 6 and 9 months were also estimated. Secondary outcomes were analyzed similarly, adjusting for multiple comparisons using the Šídák method.

Patient activation improved significantly relative to the control group from baseline to 3 months (+4.62 vs. +0.15, p = .024). These improvements were sustained at 6 (p = .001) and 9 months (p = .042). Communication self-efficacy improved (+3.65 vs. +1.10, p = .04) at 3 months. These improvements persisted at follow-up points but were not significant after adjusting for multiple comparisons. Pain intensity and interference improved at 3 months (-0.65 vs. -0.03), but was not significant after adjusting for multiple comparisons (p = .069). Depression and anxiety improved more for intervention participants, but after adjustment, improvements were not significant.

COOPERATE effectively increased patient activation, the study’s primary outcome, and these increases were sustained over time. Communication self-efficacy similarly improved, although was not sustained. Additional analyses are planned, including mediation and moderation analyses to better understand mechanisms of action. Furthermore, because the COVID-19 pandemic began midway through the trial, analyses are planned to ascertain potential differences in outcomes for participants who completed the trial pre-pandemic.

Despite numerous efforts toward health equity, disparities in pain care persist. Intervention is needed at all levels, including the individual and system level. COOPERATE represents a promising approach to decrease disparities at the individual level by activating and equipping Veterans to advocate for themselves and thus may be an important component of efforts to achieve health equity.