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CRE 12-012
Musculoskeletal Diagnoses Cohort: Examining Pain and Pain Care in the VA
Joseph Lucien Goulet PhD MS
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: June 2013 - September 2017

BACKGROUND/RATIONALE:
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.

OBJECTIVE(S):
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.

METHODS:
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.

FINDINGS/RESULTS:
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.

IMPACT:
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.

PUBLICATIONS:

Journal Articles

  1. Fenton BT, Goulet JL, Bair MJ, Cowley T, Kerns RD. Relationships Between Temporomandibular Disorders, MSD Conditions, and Mental Health Comorbidities: Findings from the Veterans Musculoskeletal Disorders Cohort. Pain medicine (Malden, Mass.). 2018 Sep 1; 19(suppl_1):S61-S68.
  2. Buta E, Masheb R, Gueorguieva R, Bathulapalli H, Brandt CA, Goulet JL. Posttraumatic stress disorder diagnosis and gender are associated with accelerated weight gain trajectories in veterans during the post-deployment period. Eating Behaviors. 2018 Apr 1; 29:8-13.
  3. Hausmann LRM, Brandt CA, Carroll CM, Fenton BT, Ibrahim SA, Becker WC, Burgess DJ, Wandner LD, Bair MJ, Goulet JL. Racial and Ethnic Differences in Total Knee Arthroplasty in the Veterans Affairs Health Care System, 2001-2013. Arthritis care & research. 2017 Aug 1; 69(8):1171-1178.
  4. Higgins DM, Fenton BT, Driscoll MA, Heapy AA, Kerns RD, Bair MJ, Carroll C, Brennan PL, Burgess DJ, Piette JD, Haskell SG, Brandt CA, Goulet JL. Gender Differences in Demographic and Clinical Correlates among Veterans with Musculoskeletal Disorders. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017 Jul 1; 27(4):463-470.
  5. Wang KH, Goulet JL, Carroll CM, Skanderson M, Fodeh S, Erdos J, Womack JA, Abel EA, Bathulapalli H, Justice AC, Nunez-Smith M, Brandt CA. Estimating healthcare mobility in the Veterans Affairs Healthcare System. BMC health services research. 2016 Oct 21; 16(1):609.
  6. Benin AL, Fodeh SJ, Lee K, Koss M, Miller P, Brandt C. Electronic approaches to making sense of the text in the adverse event reporting system. Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management. 2016 Aug 1; 36(2):10-20.
  7. Goulet JL, Kerns RD, Bair M, Becker WC, Brennan P, Burgess DJ, Carroll CM, Dobscha S, Driscoll MA, Fenton BT, Fraenkel L, Haskell SG, Heapy AA, Higgins DM, Hoff RA, Hwang U, Justice AC, Piette JD, Sinnott P, Wandner L, Womack JA, Brandt CA. The musculoskeletal diagnosis cohort: examining pain and pain care among veterans. Pain. 2016 Aug 1; 157(8):1696-703.
Center Products

  1. Zeng Q, Garvin J, Brandt CA, Goulet JL, Bray B. Measure and Improve Healthcare Quality: Small vs Big Data Analytics. 2017 Aug 23. Available from: http://medinfo2017.org/en/wp-content/uploads/2017/09/Wednesday-23-August.pdf.
  2. Goulet JL, Zeng Q, Marshall N, Morioka C. Integrative Health Informatics: The VHA Experience. 2017 Mar 27. Available from: https://www.amia.org/jointsummits2017/panels.
VA Cyberseminars

  1. Goulet JL. The Musculoskeletal Disorders Cohort: A Resource For Collaborative Pain-Relevant Health Services Research. Spotlight on Pain Management [Cyberseminar]. 2016 Dec 6.
  2. Brennan PL. Effect of Mental Health Disorders on Pain and Pain Treatments in VHA Community Living Centers. HSR&D Spotlight on Pain Management. [Cyberseminar]. 2015 Jun 2.
Conference Presentations

  1. Hausmann LR, Brandt C, Carroll C, Fenton B, Ibrahim S, Becker W, Burgess D, Wandner L, Bair M, Goulet J. Race/Ethnicity and Total Knee Arthroplasty Rates in the VA Healthcare System: A Prospective Analysis of a Large Cohort. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  2. Hausmann LR, Brandt C, Carroll C, Fenton BT, Ibrahim SA, Becker W, Burgess D, Wandner L, Bair MJ, Goulet JL. Racial and Ethnic Differences in Total Knee Arthroplasty in the Veterans Affairs Healthcare System from 2001 - 2014. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  3. Goulet JL, Brandt CA, Kerns RD. Variation in pain NRS scores by patient and facility characteristics in a national system of care. Poster session presented at: American Pain Society Annual Meeting; 2015 May 13; Palm Springs, CA.


DRA: Musculoskeletal Disorders
DRE: Treatment - Observational
Keywords: Adverse Event Monitoring, Care Coordination, Cost-Effectiveness, Functional Status, Models of Care, Outcomes - Patient, Pain
MeSH Terms: none