Patient-Centered versus Imaging-Directed Care for Older Veterans with Chronic LBP

Veterans Health Administration, Decatur PA

Investigators

Abstract

? DESCRIPTION (provided by applicant): Chronic low back pain (CLBP) is one of the most common and complex of all chronic pain conditions among veterans and older veterans may be particularly susceptible to adverse effects of commonly prescribed treatments such as opioids, spinal injections and surgery. These treatments often are misdirected, being guided by imaging (e.g., magnetic resonance imaging) to identify degenerative disease of the lumbar skeleton that is nearly ubiquitous in older adults with and without CLBP. In contrast to this imaging-associated usual care (IAUC), we approach the care of CLBP as a syndrome, a final common pathway for the expression of multiple conditions, most of which lie outside of the lumbar spine itself such as fibromyalgia, hip osteoarthritis, anxiety and insomnia. In the context of a 2-year Rehab R&D award leading up to the current proposal, we used a modified Delphi process to create older adult-centric evaluation and treatment algorithms for each of 11 common contributors to CLBP and disability - hip osteoarthritis, fibromyalgia, myofascial pain, sacroiliac joint syndrome, lumbar spinal stenosis, lateral hip/thigh pain, leg length discrepancy, anxiety, depression, psychological maladaptation (i.e., fear-avoidance beliefs, catastrophizing), and insomnia. We refer to the comprehensive care delivered by providers that follow these algorithms as Patient-Centered Comprehensive Evaluation and Treatment (PCCET). The primary aim of the proposed pilot randomized controlled clinical trial is to evaluate the efficacy of PCCET as compared with IAUC in 50 cognitively intact veterans age 60 and older with CLBP that have undergone a lumbar MRI within the prior 30 days and have no red flags indicative of serious underlying illness requiring urgent care. Veterans will be recruited from the VA Pittsburgh Healthcare System and the Hunter Homes McGuire VA Medical Center, sites of the prior pilot study where geriatrician providers were trained in the PCCET standardized history and physical examination. Veterans will be randomized to receive either IAUC or PCCET for six months. IAUC will not be constrained. The components (including pain medication use) and location of care of participants in both arms will be tracked with monthly telephone calls. PCCET will begin with a comprehensive structured assessment to identify the contributors to CLBP and disability. A geriatrician provider trained in PCCET assessment and the associated treatment algorithms will direct and oversee care. Prior to being randomized to IAUC or PCCET, the main outcome measures will be collected on all participants: pain severity (past week average, verbal 0 to 10 scale) and pain disability (Roland Morris scale). Key cofactors that may impact outcomes will be collected with the Minimum Dataset recommended by the NIH Task Force on Research Standards for CLBP (demographics, body mass index, widespread pain, prior CLBP treatments, physical function, depressive symptoms, sleep, psychological maladaptation, alcohol/drug use, cigarette smoking). We also will collect measures of particular relevance to older veterans - medical comorbidity, pain medications, social support, health-related quality of life, mild cognitive impairment and treatment expectancy. At 6 months following randomization, pain severity and pain disability will be assessed. We hypothesize that veterans who receive PCCET will experience significantly greater reduction in pain and low back pain-associated disability than those who receive IAUC at 6 months. Participants randomized to PCCET will undergo an exit interview to identify elements of care that were particularly useful or burdensome. PCCET providers will be interviewed to identify ways to improve PCCET delivery and minimize burden on patients and providers. Both sets of interviews will be analyzed using qualitative methods. Results of the proposed pilot clinical trial will lay the essential foundation for conducting a lare multi-site randomized controlled trial. Our ultimate aim is to help move the care of our burgeoning population of older veterans in a direction that is guided by specific knowledge of their vulnerabilities, strong evidence of treatment efficacies, and a desire to optimize their independence and quality of life.