Rose Alexandra L, Coogan Shaina, Indresano Jess, Zeliadt Steven B, Chen Jessica A
Department of Psychology, University of Maryland, College Park, 4094 Campus Drive, College Park, MD, 20742, USA.
Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, VA Puget Sound Health Care System, Health Systems Research (HSR), 1660 S. Columbian Way, Seattle, WA, 98108, USA.
Implement Sci Commun. 2025 May 1;6(1):51. doi: 10.1186/s43058-025-00729-6.
The high prevalence and significant morbidity and mortality associated with chronic pain among veterans has made expansion of pain services within the Veterans Health Administration (VHA) a key priority. TelePain, in which services are provided via telehealth from central "hub" sites to patients at decentralized "spoke" sites, is one such model with positive implementation findings to date. However, the staff effort and cost of implementation have yet to be examined when considering TelePain or similar virtual hub-and spoke models of specialty pain care, information that is critical for expansion of services.
Using an established time-based activity tracker designed for implementation facilitation, study staff tracked minutes spent on implementation activities at 11 spoke sites. Annual salaries were extracted to calculate an average cost per minute for each personnel type. Costs per personnel minute were combined with activity data to calculate costs of implementation activities at spoke sites. Implementation reach outcomes for the first 36 months of implementation were extracted from the electronic health record. Service utilization data was combined with cost data to calculate cost per patient reached and per clinical encounter achieved at each site.
Total facilitation costs (range: $1,746-$7,978) and unique patients reached (range: 2-46) varied considerably across spoke sites and greater staff implementation efforts (measured in time or cost) were not associated with greater numbers of patients reached. Therefore, costs per patient reached also varied widely (range: $120-2,569) across spoke sites. Key challenges included high rurality and small clinic size; insufficient engagement of frontline providers; lack of referral options for high acuity patients; and lack of existing programming within which to situate pain services.
At spoke sites where patients were consistently referred and reached, costs were relatively modest, particularly compared to the high cost of untreated chronic pain, suggesting the potential impact of this model at scale. However, in spoke sites where referrals and encounters were low during initial implementation, cost per patient was high. Findings highlight the need for better methods for tailoring of facilitation interventions to spoke site's individual needs to maximize impact.
退伍军人中慢性疼痛的高患病率以及与之相关的显著发病率和死亡率，使得退伍军人健康管理局（VHA）扩大疼痛服务成为一项关键优先事项。远程疼痛服务（TelePain）是一种通过远程医疗从中心“枢纽”站点向分散的“分支”站点的患者提供服务的模式，迄今为止，该模式在实施方面取得了积极成果。然而，在考虑TelePain或类似的专科疼痛护理虚拟枢纽 - 分支模式时，尚未对工作人员的努力程度和实施成本进行研究，而这些信息对于服务扩展至关重要。
研究人员使用一个既定的基于时间的活动追踪器来促进实施工作，在11个分支站点追踪花费在实施活动上的分钟数。提取年薪以计算每种人员类型每分钟的平均成本。将每人每分钟的成本与活动数据相结合，计算分支站点实施活动的成本。从电子健康记录中提取实施前36个月的实施覆盖结果。将服务利用数据与成本数据相结合，计算每个站点每位接触到的患者和每次临床诊疗的成本。
各分支站点的总促进成本（范围：1,746美元至7,978美元）和接触到的独特患者数量（范围：2至46名）差异很大，工作人员更多的实施努力（以时间或成本衡量）与接触到的患者数量增加无关。因此，每个分支站点每位接触到的患者的成本也有很大差异（范围：120美元至2,569美元）。主要挑战包括高度农村化和诊所规模小；一线医疗服务提供者参与度不足；高 acuity患者缺乏转诊选择；以及缺乏将疼痛服务纳入其中的现有项目。
在患者持续被转诊并接触到的分支站点，成本相对较低，特别是与未治疗的慢性疼痛的高成本相比，这表明该模式在大规模推广时的潜在影响。然而，在初始实施期间转诊和诊疗次数较少的分支站点，每位患者的成本很高。研究结果凸显了需要更好的方法，根据分支站点的个体需求调整促进干预措施，以最大限度地发挥影响。
