Among Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn (OEF/OIF/OND) Veterans, painful musculoskeletal disorders are the most common medical conditions, surpassing all mental health conditions combined. For OEF/OIF/OND Veterans with traumatic brain injury (TBI), chronic pain is highly co-prevalent and is recognized as a component of the "polytrauma triad" along with TBI and PTSD. Given the high prevalence of chronic pain in this population, and its negative effects on the management of other chronic conditions, combined with high barriers to engagement in clinic-based services and prevalence of smartphone ownership, OEF/OIF/OND Veterans are ideal potential users of the recently developed VA Pain Coach mobile application (app). The app provides pain education, facilitates assessment and monitoring of pain-relevant outcomes, and teaches evidence-based pain self-management skills. Although VA has invested in mobile health technology and mobile apps represent a growing industry in general, little is known about app integration into clinical care, patients' interest in app use, and how to promote and support app use in the clinical setting. We assessed the potential for expanding the use of the VA Pain Coach app to target the broader healthcare setting and examine Veteran and Patient Aligned Care Team (PACT) interest in using a brief stepped intervention to promote use of the app. Results of this study can be used to inform a planned implementation trial of the stepped intervention.
The proposed study will assess the potential for expanding the use of the VA Pain Coach mobile app for patient self-management of chronic pain to target primary care settings and examine Veteran and Patient Aligned Care Team (PACT) interest in using a brief stepped intervention to promote use of the app. Outcomes of interest will be: 1) Veteran and PACT interest in the VA Pain Coach app, 2) factors associated with implementation success, and 3) Veteran and PACT interest in adopting a brief stepped intervention provided in the primary care setting designed to promote and facilitate use of the app.
This study was a two-site, mixed-methods pre-implementation study conducted in two concurrent phases. We surveyed PACTs which include primary care providers, nurses and primary care-mental health integration (PCMHI) providers regarding interest in and feasibility of recommending and using the app to promote pain self-management with OEF/OIF/OND Veterans, including 1) acceptance of technology in Veteran care, 2) current practices in pain self-management training or referral and associated barriers and facilitators, and 3) perceptions of factors affecting uptake and use of the app using constructs from the Consolidated Framework for Implementation Research (CFIR). Next, informed by the survey results, we conducted individual, semi-structured interviews with a purposive sample of PACT members, nurses, and PCMHI clinicians to assess key implementation factors using the CFIR model and to assess the implementation context for a proposed stepped intervention. Concurrently, we surveyed OEF/OIF/OND Veterans with chronic musculoskeletal pain to assess: 1) barriers and facilitators to using apps and pain self-management in general, and 2) information technology use, acceptance and literacy. Next, informed by survey results, we will conduct individual semi-structured Veteran interviews using CFIR constructs to assess Veteran perspectives on key implementation factors and barriers and facilitators to engaging in the proposed stepped intervention.
PACT Staff: PACT staff surveys (N=61; VA Connecticut=37, VA Boston=24) and interviews (n=20; VA Connecticut=10, VA Boston=10) have been completed. PACT staff survey respondents were mostly female (69.5%) and White (64.4%). Surveyed PACT staff represented a variety of professions including physicians (n=18), psychologists (n=8), PA/APRNs (n=5), RNs (n=16), and health technicians/others (n=14). PACT staff reported that their current frequency of recommending the use of specific mobile apps to patients was low, with 43% indicating "never" recommending apps or being "not aware" of apps and only 32% indicating that they recommend apps "sometimes". The majority reported never demonstrating how to use the apps (47.5%) or using app data to track patients' health between visits (47.5%). Regardless of current practices, a majority of the providers surveyed responded that they were very likely to recommend the VA Pain Coach to patients (49.1%), demonstrate the app to patients during an appointment (31.5%), and use the app collaboratively with patients for goal setting (32.1%). The three most commonly endorsed facilitators for recommending the pain app to patients included: the availability of technical support for using the VA Pain Coach, clear instructions about how to best recommend VA Pain Coach to patients with chronic pain, and their own or colleagues perception that pain management is necessary. In contrast, the three factors that were rated as the least important for facilitating use of the pain app in the PACT setting were: incentives given for recommending or using the Pain Coach app with patients, commitment of administrative leaders in promoting use of the VA Pain Coach, and the provider's belief in their ability to use the VA Pain Coach with patients. Although qualitative analysis has not been completed, themes that have emerged in qualitative interviews with PACT providers included beliefs that apps would be especially well-received among younger and already motivated patients and that the pain coping skills training portion of the app would be particularly important in promoting patients attaining improvement in the pain and functioning. When asked about the proposed stepped care intervention, providers reported more support for recommending the app with the patient using the app on their own, not collaboratively with the provider. A primary concern about using the app collaboratively with patients, either demonstrating it to patients or providing feedback on patient-reported tracking data, was concern about limited time during appointments, especially with patients who have multiple comorbid conditions. For this reason, use of the app with the support of a PACT nurse was favored by physician respondents.
Patients: Thus far over 347 surveys have been mailed and 39 patients have returned the survey, yielding a response rate of approximately 11%. The mean age of respondents in this OEF/OIF sample was 37.5. The majority were White (64%) and male (59%). The majority of participants endorsed having PTSD (66%), whereas many fewer endorsed traumatic brain injury (18%) and military sexual trauma (8%). Eighty-five percent of participants reported owning a smart phone and 30% of those reported using a health-related app in the past. A majority of respondents reported that they had learned or used pain self-management strategies in the past (58%). When asked if they would enroll in a pain self-management program, 28% reported being definitely be interested and 68% reported they would consider enrolling. With regard to the VA Pain Coach app, 21% of respondents indicated that they were interested in using it and 74% reported that they would consider using the app. When asked how they would prefer to use the app, more said they would prefer using the app collaboratively with their provider (i.e., sharing the app tracking data with their provider or obtaining provider feedback on the app data) rather than use the app on their own. Finally, the factor that was most likely to diminish interest in using the app was concern about privacy and the security of personal information (24%). Concerns about the efficacy of self-management in general or self-management using an app were present, but small (11% and 19%, respectively).
In summary, both PACT staff and Veterans report a willingness to use the VA Pain Coach. A large majority of patients reported owning a smartphone and approximately one third had used a health-related app in the past. Providers reported the primary barrier to use of the app with patients is limited time in visits. Clear instructions regarding when to recommend the pain app and technical support for app use were endorsed as important factors in future use.
Both PACT staff and Veterans reported interest in using the VA Pain Coach in the PACT setting, though Veterans reported more interest in using the app collaboratively with their provider (monitoring of app data and feedback from provider). Providers reported a preference for PACT nurses to monitor patient data and provide feedback.
Successful implementation of the VA Pain Coach will require specific support for staff in recommending and using the app with patients. Efforts to harmonize patient and provider preferences for use will likely increase uptake and satisfaction.
This study will leverage the VA's investment in the Pain Coach app by identifying factors to facilitate its widespread use for pain self-management by PACTs and OEF/OIF/OND Veterans, and inform the use of other VA-developed apps for chronic condition self-management. This study advances two priority goals of the PT/BRI-QUERI : to enhance evidence-based, integrated, Veteran-centered care and to improve Veterans' self-management of chronic conditions. Data from this study will inform future research to 1) develop and test a clinician toolkit for Pain Coach app dissemination to Veterans and PACT use with Veterans, and 2) develop and test a PACT-facilitated stepped intervention composed of three strategies to promote Veteran use of the app. Additionally, results from this study will inform the implementation of the VA Pain Coach in the PACT setting.
None at this time.
Brain and Spinal Cord Injuries and Disorders
Technology Development and Assessment
Implementation Science, QUERI Implementation