VA Transitional Pain Service Study (VATPS)

Reducing Chronic Opioid Use Among Veterans Undergoing Community Care Surgery Using a Transitional Pain Service

The VA Community Care Program has provided an important resource to improve access to surgical care for Veterans unable to have treatment at VA Medical Centers (VAMC). However, there is an increased risk of developing chronic opioid use when at-risk surgical patients receive opioids from non-VA providers. A multidisciplinary approach to perioperative pain management known as the Transitional Pain Service (TPS) has been shown to effectively reduce chronic opioid use among Veterans after surgery, but it is unknown whether it can be used to achieve the same outcomes for Veterans using Community Care for high-risk surgery. Through this project, the investigators will generate important data to establish whether a telehealth TPS approach can serve as a scalable and effective strategy to ensure safe opioid use among Veterans undergoing orthopedic surgery. The investigators will randomize Veterans using Community Care for orthopedic surgery to telehealth TPS versus standard of care. Finally, the investigators will interview patients using Community Care to better understand barriers and facilitators to telehealth TPS and Veteran satisfaction with the approach to pain management.

Study Overview

• Status: Recruiting
• Conditions: Chronic Opioid Use
• Intervention / Treatment: Behavioral: Transitional Pain Service

Detailed Description

The Transitional Pain Service (TPS) is a novel perioperative surgical home approach that consists of comprehensive nurse care coordination before, during and for at least 6-months after surgery for Veterans at risk for chronic opioid use (COU). This program is specifically focused on 1) reducing suffering from pain and improving functional recovery after surgery; 2) preventing the development of new COU after surgery; and 3) assisting patients already on chronic opioids to taper and completely transition off narcotics during their recovery from surgery. Veterans on chronic opioids, or those identified to be at risk for persistent opioid use after surgery, are enrolled into TPS where a personalized pain management plan is developed and followed until opioid tapering is complete, or until a warm handoff can be made to their VA Primary Care Provider (PCP) to ensure continuity of care. Each Veteran's individualized pain management plan can be viewed on a SharePoint health information technology dashboard that provides clinical decision support to all VA health care providers (i.e., TPS nurse care coordinators, surgeons, VA PCPs, etc.) who provide care before and after surgery (Figure 1). Pain management and opioid use for all patients enrolled into TPS is assessed at baseline and after surgery using morphine equivalent daily dose (MEDD), and patient-reported outcomes using measures from the Patient-Reported Outcome Measurement System (PROMIS) for pain intensity (PROMIS 3a), pain interference (PROMIS 6b), and a pain catastrophizing scale (PCS) score. The TPS approach utilizes numerous evidence-based strategies that can be applied during the preoperative and postoperative period as a means to reduce opioid use and prevent CPSP among Veterans undergoing surgery at non-VA community hospitals. This includes individually tailored programs for preoperative education or pain management planning; referral for non-pharmacologic modalities such as cognitive based intervention; as well as a coordinated approach to post-discharge instructions and transitions of care. Each of these individual strategies by themselves has been shown to have an effect on improving postoperative pain management, and each is supported by current professional guidelines for the management of postoperative pain.

For Aim 1, the investigators will use claims data for opioid prescriptions submitted by non-VA surgeons across nationwide hospitals captured using the Program Integrity Tools (PIT) system for Office of Community Care data (2018-2020), and compare to pharmacy claims data for opioids prescribed to Veterans who underwent orthopedic surgery at VAMC. A risk-adjusted analysis will help determine whether non-VA surgeons are prescribing a higher quantity of opioids after surgery than VA providers. For Aim 2, the investigators will randomize Veterans from two VA medical centers who are referred for orthopedic surgery using Community Care to a transitional pain service with regular follow-up telehealth visits after surgery versus standard care. For Aim 3, the investigators will perform a qualitative study to determine what components of the telehealth TPS intervention have the greatest impact on reducing opioid use and increasing tapering after surgery at non-VA hospitals, and how often are these interventions being used as part of standard post-operative care? Semi-structured interviews will be conducted among Veterans who underwent orthopedic joint surgery at non-VA hospitals, both with and without the telehealth TPS intervention, to examined post-operative opioid usage and identify specific factors that facilitated or impeded opioid tapering.

• Study Type: Interventional
• Enrollment (Estimated): 400
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Benjamin S Brooke, MD PhD; Phone Number: 4169 (801) 582-1565; Email: Benjamin.Brooke@hsc.utah.edu
• Study Contact Backup: Name: Michael J Buys, MD; Phone Number: 6617 (801) 582-1565; Email: michael.buys3@va.gov

Study Locations

• United States
  • Utah
    • Salt Lake City, Utah, United States, 84148-0001
      • Recruiting
      • VA Salt Lake City Health Care System, Salt Lake City, UT
      • Contact: Amyanne Wuthrich, MS BS; Phone Number: 4169 801-582-1565; Email: Amyanne.Wuthrich@va.gov
      • Contact: Lisa A O'Hara; Phone Number: (801) 582-1565; Email: lisa.o'hara@va.gov
      • Principal Investigator: Benjamin S Brooke, MD PhD
      • Sub-Investigator: Michael J Buys, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

Aims 1 & 3:

• The investigators will include Veterans who are referred to the Veteran Community Care Program (VCCP) for an orthopedic surgery procedure from any VA medical center throughout VISN-19.
• Additionally, these Veterans must be 18+ years of age who are not on chronic opioids at the time of surgery, and who have a VA primary care provider (PCP).

Aim 2:

• Veterans who received TPS (Aim 1) and referring VA Primary Care Providers.

Exclusion Criteria:

Aim 1:

• The investigators will exclude Veterans who are scheduled for other types of surgical procedures, are on chronic opioid therapy before surgery, are on hospice or end-of-life care, are cognitively impaired, or unable to complete the follow-up visits for any other reason.

Aim 2:

• The investigators will exclude Veterans not randomized to the TPS Telehealth intervention of Aim 1.

  • Primary Care Providers will be excluded if they do not primarily work at the VA.

Aim 3:

• The investigators will exclude Veterans who were not randomized to the TPS Telehealth intervention.
• Veterans who experienced a major complication during the perioperative period or experienced an extended length of stay (LOS) based on exceeding the upper interquartile range of median LOS.
• Exclusion criteria for this aim also include patients on hospice care, individuals discharged to a care facility, and those with scheduled readmissions for follow up procedure(s) within 90-days.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Telehealth Transitional Pain Service + Standard Postoperative Follow-Up Care	Behavioral: Transitional Pain Service; The Transitional Pain Service (TPS) is a novel perioperative surgical home approach that consists of comprehensive pain management and care coordination before, during and for at least 6-months after surgery for Veterans at risk for chronic opioid use (COU).
Active Comparator: Standard Follow Up Care	Behavioral: Transitional Pain Service; The Transitional Pain Service (TPS) is a novel perioperative surgical home approach that consists of comprehensive pain management and care coordination before, during and for at least 6-months after surgery for Veterans at risk for chronic opioid use (COU).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Persistent post-surgical opioid use	The percentage of non-chronic opioid use Veterans who continue post-surgical use past 90 days after surgery.	90 days after surgery

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quantity of opioids prescribed (MME/day)	Number of opioid tablets prescribed at discharge and in the first 90-days after surgery.	90 days after surgery
PROMIS Assessment of Pain Intensity and Pain Interference	Pain and functional patient reported outcomes using the NIH PROMIS Assessment of Pain Intensity (3a) and Pain Interference (6b). Reported as T-scores, where the average is a score of 50 and standard deviations are 10 points. A higher score represents worse pain/pain interference.	7, 30, 60, and 90-days after surgery
Assessment of Care Coordination	Assessment of care coordination during transitions using the Care Transitions Measure (CTM-15). All questions use a five-point Likert response scale comprising 'strongly disagree', 'disagree', 'neutral', 'agree' and 'strongly agree'. A single total score ranging from 0 to 100 is calculated from the CTM-15, with higher scores indicating better care transition.	7 days after surgery
Visit with Primary Care Provider within 30 days after surgery.	Determination of whether Veterans had a visit with their Primary Care Provider within 30 days after surgery. This is a yes/no outcome.	30 days after surgery
Number of opioid refills after discharge from surgery	The number of opioid prescription refills received after discharge from surgery and by 90-days after surgery.	Between discharge from surgery and 90-days after surgery
Number of opioid tablets used in the 90 days after surgery	The difference between the number of tablets prescribed and the number of tablets left over as reported by the patient at 90 days after surgery.	90 days after surgery
Date of last opioid use	The date that the patient last used an opioid medication after surgery, as reported by the patient. This will be asked at days 7, 30, 60, and 90 after surgery.	90 days after surgery

Collaborators and Investigators

• Sponsor: VA Office of Research and Development
• Investigators: Principal Investigator: Benjamin S Brooke, MD PhD, VA Salt Lake City Health Care System, Salt Lake City, UT

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2024
• Primary Completion (Estimated): January 1, 2026
• Study Completion (Estimated): January 1, 2027

Study Registration Dates

• First Submitted: January 11, 2024
• First Submitted That Met QC Criteria: January 23, 2024
• First Posted (Actual): January 25, 2024

Study Record Updates

• Last Update Posted (Actual): April 1, 2024
• Last Update Submitted That Met QC Criteria: March 28, 2024
• Last Verified: March 1, 2024

More Information

Terms related to this study

• Keywords: Post-operative pain; Opioid use disorder; Opioid misuse; Community Care; MISSION Act; Transitional Care Coordination
• Other Study ID Numbers: IIR 22-062

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No