COVID-19 Impact on Pain management: Highlighting, Explaining, and Realigning services (CIPHER)

Background: The COVID-19 pandemic severely disrupted healthcare. These changes are likely to have especially profound implications for Veterans obtaining regular care for chronic conditions, such as chronic pain-particularly when Veterans are obtaining nonpharmacologic treatments, which often require regular, in- person visits. Although virtual care delivery in VA increased dramatically in response to the pandemic and is unlikely to diminish, it is unclear what services Veterans with pain have received via virtual delivery and how Veterans have been affected by these shifts. The goal of this project is to understand changes in VA chronic pain care after COVID-19 and their associated impacts-and use these data to develop strategies to optimize delivery of VA pain services in a post-COVID-19 environment. Significance: This project addresses priorities in HSR&D's Targeted Solicitation on Opioid Safety and Opioid Use Disorder. Specifically, this project is responsive to priority area E, "examination of the impact of the COVID-19 public health emergency on the effective treatment of chronic pain, including effects on access to care, medication and treatment modalities, patient function and satisfaction." Despite the clear impact on care delivery exerted by the COVID-19 pandemic, little is known about how these changes and disruptions have affected Veterans and their chronic pain care, including their ability to access care after the onset of the pandemic. These concerns are reflected in our pilot data, which indicate that Veterans have felt the impact of service disruptions on their pain management. Innovation and Impact: The effects of the COVID-19 pandemic are not yet well-understood. This project takes a mixed-methods approach to examine changes in chronic pain care since the onset of the pandemic, working with an expert stakeholder panel at each stage of the research to ensure results and recommendations are disseminated rapidly to maximize impact. Specific Aims: Aim 1 (quantitative): Describe changes in pain management visits for Veterans with chronic low- back pain (cLBP) following the onset of the COVID-19 pandemic. Aim 2 (qualitative): Explain differential patterns of receipt of services identified in Aim 1 and perceived impacts. Aim 3: Share findings throughout the project, including final, integrated findings from Aims 1 and 2, and develop short- and long-term strategies to optimize delivery of pain care for Veterans in a post-COVID-19 environment. Methodology: This study uses an embedded mixed-methods design. In Aim 1 a retrospective cohort of Veterans receiving care for cLBP will be established. Receipt of guideline-recommended, nonpharmacological pain management services, including changes in service receipt following the onset of COVID-19, will be examined. Veteran and facility factors associated with differential changes will be tested. Once the first phase of Aim 1 analyses is complete, qualitative sampling for Aim 2 will begin. Thus, consistent with an embedded design, most Aim 1 and Aim 2 activities will take place concurrently. Qualitative interviews with clinicians, administrators, and Veterans will be conducted to better understand how they experienced pandemic-related changes, including any effects on their current practice/service delivery, and to identify positive changes made since the pandemic that could serve as examples for other facilities. In Aim 3 we will work with our stakeholder advisory panel, led by the VA Office of Pain Management, to develop comprehensive recommendations to guide VA on policies to optimize delivery of pain management services in a post-COVID-19 environment. Next Steps: Findings will be directly applied to VA care, as directed by the CIPHER stakeholder panel (led by the VA National Pain Management Office). Future research will examine implementation strategies aimed at supporting VA-wide implementation.