Marianne Susan Matthias

Interests

Research

Pain management, healthcare disparities, patient-provider communication, patient engagement, patient empowerment, shared decision-making, nonpharmacological pain treatments, behavioral health, clinical trials, qualitative methods

Courses

No activities entered.

Scholarly Contributions

Journals/Publications

• Griffin, A. C., Javier, S. J., Golding, M., Runnels, T. W., Matthias, M. S., Shimada, S. L., Higgins, D. M., Zulman, D. M., & Midboe, A. M. (2025). Designing Patient-Friendly Messages: Tutorial on Applying Human-Centered, Self-Determination Theory With AI Considerations. Journal of Medical Internet Research, 27(Issue 1). doi:10.2196/78173
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  Patient messaging technologies offer treatment information and recommendations through web-based platforms, patient portals, mobile apps, and SMS text messaging. Many of these technologies have started to incorporate messages that are crafted by artificial intelligence (AI). Such tools are most effective when constructed with theoretical grounding and iterative input from end users. Thus, we outline a human-centered design approach for developing patient messaging content that aligns with self-determination theory (SDT), a widely used framework that has shown positive impacts on health behavior change. We illustrate our approach step-by-step for the development of messages that promote evidence-based treatment opportunities for patients with chronic pain. Messages were initially developed by subject matter experts and refined using SDT constructs (autonomy, competence, and relatedness) and motivation and behavior change techniques. Using a rapid prototyping approach, we sequentially met with 3 patient engagement boards to elicit feedback on message prototypes and enhance their content. We synthesized and aligned disparate feedback across boards with SDT and motivation and behavior change techniques. Drawing upon the input from the engagement boards, existing co-design approaches, and the field of human-centered AI, we recommend strategies to collaborate with patient partners to enhance the readability and clarity of messaging content. Recommended strategies include (1) involve engagement boards early in messaging framing and modality selection, (2) represent diverse perspectives when refining messages, (3) acknowledge and set expectations to integrate unique experiences and views, (4) prioritize message tailoring for the population of interest, (5) incorporate continual feedback mechanisms, and (6) keep the human interaction in patient-facing messages. By illuminating the process of developing message content that aligns with SDT constructs and providing guidance for iterative patient engagement and practical prototyping, we hope this tutorial can be used to enhance patient messaging content and improve uptake of evidence-based treatments. Our approach and recommendations can also guide multidisciplinary research and design teams to build patient-centered health messages. This tutorial has special consideration for future AI-guided messaging interventions, as patients are typically not involved in message content development or framing, but early engagement can potentially mitigate known AI concerns related to privacy, transparency, and fairness. As technologies and patient populations change over time, linking continual end user input with theoretical grounding plays a key role in simplifying complex medical information and promoting understanding of treatment opportunities that can ultimately improve health outcomes.
• Imperiale, T. F., Cheng, M., Thomas, M. R., & Matthias, M. S. (2025). A qualitative study of a new metric for estimating early-onset colorectal cancer risk in male veterans: “Colon Age”. BMC Primary Care, 26(Issue 1). doi:10.1186/s12875-025-02854-6
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  Background: In several Western nations, cancers of the colon and rectum have been steadily increasing in persons younger than age 50. Although the age at which to begin colorectal cancer (CRC) screening in the U.S. was lowered to 45 years in 2018, uptake of screening in persons aged 45–49 has been slow. Based on risk factors for CRC prior to age 50 and population-based CRC prevalence data, we previously defined a new metric for estimating the risk of CRC prior to age 50 called “Colon Age”. The objective of this study was to obtain qualitative data on the acceptance, feasibility, and clinical utility of this metric from patients and primary care providers. Methods: With permission from their providers, we recruited a convenience sample of average-risk male patients 35–49 years of age during their primary care appointment. Primary care providers were recruited through email invitation. Following informed consent, two interviewers conducted semi-structured qualitative interviews with participants. Interviews were conducted until saturation was reached. Interviewers were not involved in the tool’s development. The audio-recorded interviews were transcribed, de-identified, and analyzed using the constant comparison method. Results: Thirty-one (23 male Veteran patients, 8 primary care providers) interviews were conducted. Patients (mean age 47 years, 100% male) expressed willingness to follow screening recommendations from their provider, although most were unaware of other screening options beyond colonoscopy. Overall, patients expressed acceptance of the Colon Age concept and tool, finding it easy to understand, helpful for staying informed of their health, and a way to empower themselves in their screening decisions. Providers (mean age 53 years; 50% female) also found the tool acceptable, commenting on its usefulness for starting screening conversations with patients and improving screening uptake. Providers questioned the tool’s time commitment, consistency with practice guidelines, and the process of tool development. Conclusions: In this age of precision medicine, the Colon Age tool—despite some limitations—appears to be useful to patients and providers in individualizing risk for CRC and may improve uptake of screening in persons younger than age 50.
• Lee, J. L., Donnelly, C. E., Hirsh, A. T., Weiner, M., Sperry, H. A., Fuqua, M. R., Natividad, D., & Matthias, M. S. (2025). Role of the Veterans Health Administration’s LGBTQ+ Veteran Care Coordinators in Facilitating Care for Transgender and Gender-Diverse Veterans. Permanente Journal, 29(Issue 1). doi:10.7812/tpp/24.161
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  INTRODUCTION: Transgender and gender-diverse (TGD) individuals frequently encounter discrimination in health care settings. The Veterans Health Administration (VA) is committed to addressing the health disparities experienced by TGD veterans. The purpose of this study was to explore the experiences of TGD veterans with LGBTQ+ veteran care coordinators. METHODS: The authors conducted semi-structured interviews with TGD veterans with depression between January and March 2022. Participants were recruited with assistance from the VA’s network of LGBTQ+ veteran care coordinators. Interviews were recorded, transcribed, and analyzed. RESULTS: Twenty-six TGD veterans participated in the study, with a range of experiences, both positive and negative, with LGBTQ+ veteran care coordinators. Veterans spoke of the role of coordinators in educating both patients and clinicians about TGD health care needs. Participants who expressed dissatisfaction with their coordinators highlighted the need for a clearer definition and communication of coordinator duties. CONCLUSIONS: This study highlights the important roles played by the VA LGBTQ+ care coordinators in addressing the needs of TGD veterans. The study also points to an immense need for clinician education in TGD care. Further training and education are recommended to improve equitable care for TGD veterans.
• Levoy, K., Torke, A. M., Longtin, K., Matthias, M. S., & Hickman, S. E. (2025). A Pilot Study of a Primary Palliative Care Communication Intervention (PRECURSOR) to Address Supportive Oncology Needs for Patients With Incurable Cancer and Their Caregivers in the Outpatient Oncology Setting. Cancer Control, 32(Issue). doi:10.1177/10732748251390952
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  Introduction: As cancer care increasingly shifts to outpatient settings, patients with incurable cancer and their caregivers face growing challenges in addressing supportive oncology needs across five domains: informational, physical, emotional, social, and spiritual. Integration of supportive care in routine oncology practice—or primary palliative care—remains limited. Oncology encounters prioritize clinical agendas, leaving little time for supportive care and setting the stage for adverse outcomes. This study pilot tested a primary palliative care communication intervention, PRECURSOR (NCT05995860), using a nonrandomized (10 usual care control, 10 intervention) approach in a gynecology oncology clinic. Methods: PRECURSOR combines a brief Freelisting activity—used to elicit communication intentions about supportive oncology needs among patients, caregivers, and providers—with an educational handout on the five domains of supportive oncology needs. Primary outcomes were feasibility (≥25% enrollment rate; ≥4 enrollments/month) and acceptability (overall and by component). Exploratory outcomes were communication behaviors (qualitatively coded from audio-recorded encounters) and post-encounter outcomes (via surveys). Results: Of 1356 screened, 78 were eligible, and 20 enrolled (26%) in 38 weeks (2 enrollments/month). Most (70-78%) patients, caregivers, and providers rated PRECURSOR as acceptable overall. Patients and caregivers found both components acceptable, but providers favored the educational handout. Among exploratory outcomes, a greater proportion of the supportive oncology needs discussed during encounters were initiated by patients in the intervention group (46%), compared to control (37%). Average distress and anxiety scores were lower in the intervention group. No other patterns were observed among the exploratory outcomes. Qualitative findings indicated PRECURSOR was valuable, but refinements were suggested to increase impact. Conclusions: PRECURSOR was a feasible and acceptable primary palliative care communication intervention in the outpatient oncology setting. PRECURSOR holds potential to foster more patient-centered communication about supportive oncology needs and improve the psychological well-being of patients and caregivers facing incurable cancer, though refinements are needed.
• Matthias, M. S., Burgess, D. J., Daggy, J. K., Donnelly, C. E., Flores, P., Fowler, N. R., Garabrant, J., Henry, N., Henry, S. G., Huffman, M., Kavuri, P. J., Ofner, S., Perry, C., Rand, K. L., Robles, M., Salyers, M. P., Taylor, S. L., & Hirsh, A. T. (2025). Equity Using Interventions for Pain and Depression (EQUIPD): A pilot randomized trial. Journal of Pain, 29(Issue). doi:10.1016/j.jpain.2025.105353
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  Despite increased calls for improved health equity, Black patients continue to experience worse pain and associated outcomes. Black patients are also offered fewer pain treatment options than White patients and report poorer quality communication with clinicians, including lower participation in shared decision-making. Comorbid depressive symptoms can impede effective pain management and participation in decision-making. The Equity Using Interventions for Pain and Depression (EQUIPD; NCT05695209) pilot study examined feasibility of a one-on-one coaching intervention, paired with a decision aid, to facilitate shared decision-making about evidence-based nonpharmacological pain treatments for Black patients with chronic musculoskeletal pain and symptoms of at least mild depression. We recruited and randomized 30 participants at a rate of 7.5 per month, with 90% retention at 3 months and 87% at 6 months. Intervention participation was high, with 94% of participants completing at least 3 of 4 coaching sessions. Fidelity was also high. Although not powered for effectiveness, most outcomes, including pain interference, depression, anxiety, patient engagement, and shared decision-making, improved, favoring the intervention, with effect sizes ranging from 0.30–0.75 at 3 months. Results indicate that EQUIPD holds promise as an intervention to support autonomy and shared decision-making for Black patients with chronic pain and elevated depressive symptoms. Perspective: The EQUIPD intervention, which included one-on-one coaching combined with a decision aid to increase shared decision-making about nonpharmacological pain treatments, was feasible and shows promise in improving pain and related outcomes for Black patients with chronic musculoskeletal pain and depressive symptoms.
• McGuire, A., Flanagan, M., Stout, M. E., Coffing, J., Kukla, M., Traylor, M., Myers, L., Henry, N., Carter, J., & Matthias, M. (2025). Use of Cognitive-Behavioral Therapy in a Nation-Wide Veterans Health Administration Sample: The Role of Clinic, Therapist, and Patient Factors. Health Services Research, 60(Issue 4). doi:10.1111/1475-6773.14604
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  Objective: To examine the use of CBT-CP (Cognitive-behavioral therapy for chronic pain) by CBT-CP-trained therapists to treat patients with pain over a five-year period (October 2015–February 2020). Data Sources and Study Setting: CBT-CP is a core evidence-based practice that is central to multidisciplinary chronic pain care. However, research suggests that CBT-CP is underused. The current study used national Veterans Health Administration data to examine the use of CBT-CP by CBT-CP-trained therapists to treat patients with pain over a five-year period. Study Design: Multilevel modeling was used to evaluate clinic, therapist, and patient-level factors as predictors of CBT-CP receipt. Data Collection: Administrative data on 37,514 patients seen at a national sample of Veterans Health Administration locations for pain were collected from the U.S. Veterans Health Administration central data repository. Principal Findings: Results indicated 38.4% of patients with pain seen by a CBT-CP-trained therapist received CBT-CP during the observation period. Patients were more likely to receive CBT-CP if more time elapsed since their therapist received CBT-CP training and if their therapist had a master's degree (vs. a doctorate). Patients with somatic symptom disorder and depressive disorders were more likely to receive CBT-CP, while patients with comorbid personality disorders or substance use disorders were less likely to receive CBT-CP. Patients seen in pain specialty, PTSD, biomedical, and mental health clinics were more likely to receive CBT-CP than those not seen in these clinics. Conclusions: Findings suggest that the reach of CBT-CP is substantively related to factors at each level. Future research is needed to better understand the therapy treatment decision-making processes and to address education gaps and other factors that impede the implementation of evidence-based practices.
• Mosher, C. E., Lewson, A. B., Austin-Wright, M., Matthias, M. S., Helft, P. R., Turk, A. A., Loehrer, P. J., Sehdev, A., Al-Hader, A. A., & Johns, S. A. (2025). Acceptance and commitment therapy in metastatic gastrointestinal cancer: patient and caregiver qualitative study. BMJ Supportive and Palliative Care. doi:10.1136/spcare-2025-005548
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  Objectives: Acceptance and commitment therapy (ACT) is a promising behavioural intervention to improve quality of life in patients with advanced cancer and their family caregivers. Little qualitative research has examined the effects of ACT in cancer populations. Thus, this qualitative study examined the perceived impact of ACT, including mindfulness practice and values-based action, on patients with advanced gastrointestinal (GI) cancer and their family caregivers. Methods: Individual, semistructured qualitative interviews were conducted with 13 patients with stage IV GI cancer and 14 family caregivers following their participation in a six-session ACT intervention. Data were analysed using an immersion/crystallisation approach. Results: Most participants identified benefits of ACT that facilitated their adjustment to cancer or caregiving. Patients and caregivers described several effects of mindfulness, including improved management of fatigue and other symptoms, improved emotion regulation skills and an ability to savour the present moment. Some participants reported misperceptions of the purpose of mindfulness, such as emptying the mind of thoughts or relaxing. In addition, engaging in actions based on personal values often led to patient empowerment (eg, renewed sense of purpose in life), improved caregiver self-care and better relationship quality between patients and caregivers. Conclusions: Results raise hypotheses about potential mechanisms and outcomes of ACT interventions that warrant examination. Findings also suggest that enhancing education on mindfulness in ACT interventions may reduce conceptual misunderstandings. Finally, results suggest that a dyadic ACT intervention may improve relationship functioning between family members.
• Burgess, D. J., Calvert, C., Bangerter, A., Branson, M., Cross, L. J., Evans, R., Ferguson, J. E., Friedman, J. K., Hagel Campbell, E. M., Haley, A. C., Hennessy, S., Kraft, C., Mahaffey, M., Matthias, M. S., Meis, L. A., Serpa, J. G., Taylor, S. L., & Taylor, B. C. (2024). Do mindfulness interventions cause harm? Findings from the Learning to Apply Mindfulness to Pain (LAMP) Pragmatic Clinical Trial. Pain Medicine (United States), 25(Issue 1). doi:10.1093/pm/pnae056
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  Background: Although mindfulness-based interventions (MBIs) are widely used in clinical and nonclinical settings, there has been little systematic study of their potential risks. To address this gap, we examined differences in psychological and physical worsening among participants in the usual care and intervention conditions of a 3-group, randomized pragmatic trial (Learning to Apply Mindfulness to Pain [LAMP]) that tested the effectiveness of 2 approaches to delivering MBIs to patients with chronic pain. Methods: The sample consisted of 374 male and 334 female patients with chronic pain enrolled in the LAMP trial who completed a 10-week follow-up survey, 61% of whom had a mental health diagnosis. Psychological and physical worsening was assessed by a checklist asking whether participants experienced specific symptoms since beginning the study. We used multivariable logistic regression models with imputed data to determine whether predicted probabilities of increased symptoms differed between usual care and the 2 MBIs. Results: Participants in usual care were more likely to report experiencing increased psychological and physical worsening than were those in the MBIs, including an increase in disturbing memories; sadness, anxiousness, and fatigue; isolation and loneliness; and feeling more upset than usual when something reminded them of the past. Conclusions: MBIs do not appear to cause harm, in terms of increased symptoms, for this population of patients with chronic pain and high levels of mental health comorbidities. Clinical trial registration: Preregistration with an analysis plan at www.ClinicalTrials.gov: NCT04526158. Patient enrollment began December 4, 2020.
• Burgess, D. J., Calvert, C., Hagel Campbell, E. M., Allen, K. D., Bangerter, A., Behrens, K., Branson, M., Bronfort, G., Cross, L. J., Evans, R., Ferguson, J. E., Friedman, J. K., Haley, A. C., Leininger, B., Mahaffey, M., Matthias, M. S., Meis, L. A., Polusny, M. A., Serpa, J. G., , Taylor, S. L., et al. (2024). Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial. JAMA Internal Medicine, 184(Issue 10). doi:10.1001/jamainternmed.2024.3940
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  Importance: Although mindfulness-based interventions (MBIs) are evidence-based treatments for chronic pain and comorbid conditions, implementing them at scale poses many challenges, such as the need for dedicated space and trained instructors. Objective: To examine group and self-paced, scalable, telehealth MBIs, for veterans with chronic pain, compared to usual care. Design, Setting, and Participants: This was a randomized clinical trial of veterans with moderate to severe chronic pain, recruited from 3 Veterans Affairs facilities from November 2020 to May 2022. Follow-up was completed in August 2023. Interventions: Two 8-week telehealth MBIs (group and self-paced) were compared to usual care (control). The group MBI was done via videoconference with prerecorded mindfulness education and skill training videos by an experienced instructor, accompanied by facilitated discussions. The self-paced MBI was similar but completed asynchronously and supplemented by 3 individual facilitator calls. Main Outcomes and Measures: The primary outcome was pain-related function using the Brief Pain Inventory interference scale at 3 time points: 10 weeks, 6 months, and 1 year. Secondary outcomes included biopsychosocial outcomes: pain intensity, physical function, anxiety, fatigue, sleep disturbance, participation in social roles and activities, depression, patient ratings of improvement of pain, and posttraumatic stress disorder. Results: Among 811 veterans randomized (mean [SD] age, 54.6 [12.9] years; 387 [47.7%] women), 694 participants (85.6%) completed the trial. Averaged across all 3 time points, pain interference scores were significantly lower for both MBIs compared to usual care (group MBI vs control difference: -0.4 [95% CI, -0.7 to -0.2]; self-paced vs control difference: -0.7 [95% CI, -1.0 to -0.4]). Additionally, both MBI arms had significantly better scores on the following secondary outcomes: pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and posttraumatic stress disorder. Both group and self-paced MBIs did not significantly differ from one another. The probability of 30% improvement from baseline compared to control was greater for group MBI at 10 weeks and 6 months, and for self-paced MBI, at all 3 time points. Conclusions and Relevance: In this randomized clinical trial, scalable telehealth MBIs improved pain-related function and biopsychosocial outcomes compared to usual care among veterans with chronic pain. Relatively low-resource telehealth-based MBIs could help accelerate and improve the implementation of nonpharmacological pain treatment in health care systems. Trial Registration: ClinicalTrials.gov Identifier: NCT04526158.
• Burgess, D. J., Hagel Campbell, E. M., Branson, M., Calvert, C., Evans, R., Allen, K. D., Bangerter, A., Cross, L. J., Driscoll, M. A., Hennessy, S., Ferguson, J. E., Friedman, J. K., Matthias, M. S., Meis, L. A., Polusny, M. A., Taylor, S. L., & Taylor, B. C. (2024). Exploring Gender Differences in Veterans in a Secondary Analysis of a Randomized Controlled Trial of Mindfulness for Chronic Pain. Women's Health Reports, 5(Issue 1). doi:10.1089/whr.2023.0086
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  Background: Although studies have documented higher rates of chronic pain among women Veterans compared to men Veterans, there remains a lack of comprehensive information about potential contributors to these disparities. Materials and Methods: This study examined gender differences in chronic pain and its contributors among 419 men and 392 women Veterans, enrolled in a mindfulness trial for chronic pain. We conducted descriptive analyses summarizing distributions of baseline measures, obtained by survey and through the electronic health record. Comparisons between genders were conducted using chi-square tests for categorical variables and t-tests for continuous measures. Results: Compared to men, women Veterans were more likely to have chronic overlapping pain conditions and had higher levels of pain interference and intensity. Women had higher prevalence of psychiatric and sleep disorder diagnoses, greater levels of depression, anxiety, post-traumatic stress disorder, fatigue, sleep disturbance, stress and pain catastrophizing, and lower levels of pain self-efficacy and participation in social roles and activities. However, women were less likely to smoke or have a substance abuse disorder and used more nonpharmacological pain treatment modalities. Conclusion: Among Veterans seeking treatment for chronic pain, women differed from men in their type of pain, had greater pain intensity and interference, and had greater prevalence and higher levels of many known biopsychosocial contributors to pain. Results point to the need for pain treatment that addresses the comprehensive needs of women Veterans. Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.
• Derricks, V., Hirsh, A. T., Perkins, A. J., Daggy, J. K., & Matthias, M. S. (2024). Health Care Discrimination Affects Patient Activation, Communication Self-Efficacy, and Pain for Black Americans. Journal of Pain, 25(Issue 12). doi:10.1016/j.jpain.2024.104663
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  This study examines whether a key psychosocial factor—perceiving racial discrimination in health care—is associated with worse patient activation, communication self-efficacy, and physical health outcomes for Black veterans with chronic pain. Moreover, we explore the role of physician-patient working alliance as a moderator that may alleviate the potential consequences of perceiving racial discrimination. This work is a secondary analysis of baseline data from a clinical trial with 250 U.S. Black veterans with chronic musculoskeletal pain. Participants were recruited from primary care clinics at a Midwestern VA hospital between 2018 and 2021. Perceiving racial discrimination in health care was associated with lower patient activation, lower self-efficacy in communicating with one's physician, higher pain intensity, and lower pain management self-efficacy (ps < .049) but was unrelated to reports of pain interference or use of pain coping strategies (ps > .157). Although the relationship between perceived discrimination and patient activation was moderated by working alliance (P = .014), having a stronger working alliance improved patient activation to varying degrees across levels of perceived discrimination (rather than buffering against negative outcomes when perceiving higher levels of discrimination). Moderation was not significant on any other measures. This study deepens our understanding of the broad range of health outcomes that are (not) associated with perceiving racial discrimination in health care. Contrary to prior theorizing, this work also indicates that having a strong working alliance does not attenuate the consequences of perceiving discrimination among Black individuals living with pain. These results highlight the need for system-level interventions to address perceptions of racial mistreatment in health care. Perspective: This work has important public health implications by identifying the broad range of outcomes associated with perceived discrimination in health care among Black Americans. Importantly, a strong physician-patient relationship did not buffer Black individuals from the consequences of perceiving discrimination. These findings inform intervention targets to mitigate racial health disparities.
• Matthias, M. S., Adams, J. M., & Eliacin, J. (2024). Volunteer Peer Support for Chronic Pain Self-Management: A Qualitative Study of Benefits and Barriers. Journal of General Internal Medicine. doi:10.1007/s11606-024-09217-4
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  Background: Pain self-management is a key ingredient in chronic pain management. Peer support has been shown to be effective in helping patients self-manage other chronic conditions and may be a promising approach to implementing pain self-management programs more broadly without placing additional demands on clinicians. The Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE) trial tested peer-supported chronic pain self-management. Although peers may be paid staff or volunteers, the ECLIPSE intervention was delivered by volunteer peer coaches, to test a low-resource model that could be easily implemented if effective. Trial results showed no statistically significant differences between intervention and control participants on key outcomes, and intervention adherence was low. Objective: To understand participants’ experiences with peer coaching to help explain trial results. Design: Semi-structured qualitative interviews with participants and peer coaches. Participants: Veterans with chronic musculoskeletal pain. Key Results: Benefits to intervention participation included connecting with fellow veterans, receiving encouragement and hope, and improving pain self-management. Peer coaches described benefits unique to their role: facilitating their own pain self-management, having a “positive distraction,” and a sense of “giving back.” Barriers included difficulties reaching participants; resistance to focusing on the curriculum, including prioritizing socializing and being unwilling to set pain management goals; and phone delivery, which impeded communication and rapport-building. Conclusions: Participants described benefitting from the ECLIPSE intervention. Challenges, mostly related to engagement, were also described and may help explain trial results. The low-resource nature of the intervention may have exacerbated these difficulties. Volunteer coaches typically receive less training than paid peers and may have been less prepared to handle challenges; moreover, as volunteers, peer coaches likely had competing demands that left less time for coaching. Future research should seek to identify whom to target for peer-led versus other types of interventions to maximize benefit and use of resources.
• Matthias, M. S., Bolla, A. L., Bair, S. M., Adams, J., Eliacin, J., Burgess, D. J., & Hirsh, A. T. (2024). Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): a Qualitative Analysis of a Tailored Coaching Program for Black Patients with Chronic Pain. Journal of General Internal Medicine, 39(Issue 2). doi:10.1007/s11606-023-08410-1
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  Background: Racial inequities in pain treatment are well-documented and persist despite national priorities focused on health equity. The COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) intervention was a patient-centered, tailored intervention aimed at improving health equity by targeting patient activation—the knowledge and confidence to manage one’s health. COOPERATE led to significant and sustained increases in patient activation, significant short-term increases in communication self-efficacy (confidence to communicate with clinicians), and more intervention participants experienced clinically significant (≥ 30%) reductions in pain at 3 months than control group participants. Objective: To understand how participants experienced the intervention, including their perspectives on its effects on their health and healthcare experiences. Design: Semi-structured qualitative interviews. Participants: Black veterans with chronic pain who participated in the COOPERATE intervention. Key Results: Participants described acquiring new tools and cultivating skills to use in their clinic visits, including preparing for their visit (writing an agenda, listing questions); asking focused, effective questions; and expressing concerns and communicating goals, values, and preferences. Participants indicated that by putting these tools to use, they felt more confident and able to take ownership of their own pain care; for some, this led to better pain management and improved pain. Participants expressed mixed views of disparities in pain care, with some believing race and racism did not play a role in their care, while others valued being part of an intervention that helped equip them with tools to exercise autonomy over their healthcare. Conclusions: Black patients with chronic pain described gaining greater confidence to self-manage and communicate with their clinicians after participating in the COOPERATE intervention. With its focus on empowering individuals, the COOPERATE intervention represents a promising approach to help advance equity in pain care.
• Matthias, M. S., Daggy, J. K., Perkins, A. J., Adams, J., Bair, M. J., Burgess, D. J., Eliacin, J., Flores, P., Myers, L. J., Menen, T., Procento, P., Rand, K. L., Salyers, M. P., Shanahan, M. L., & Hirsh, A. T. (2024). Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial. Pain, 165(Issue 2). doi:10.1097/j.pain.0000000000003021
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  Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one’s health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus 10.13 in control group, 95% CI: 0.48, 7.34; P 5 0.03). These improvements in the intervention group were sustained, with 17 from baseline at 6 months and 15.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.
• Matthias, M. S., Myers, L. J., Coffing, J. M., Carter, J. L., Daggy, J. K., Slaven, J. E., Bair, M. J., Bravata, D. M., & McGuire, A. B. (2024). Patterns of Opioid Prescriptions in the Veterans Health Administration for Patients With Chronic Low-Back Pain After the Onset of the COVID-19 Pandemic: A Retrospective Cohort Analysis. Journal of Pain, 25(Issue 6). doi:10.1016/j.jpain.2023.12.002
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  The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing—changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period—1 year prior to and 2 years after the pandemic's onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA. Perspective: This article examines opioid prescribing over a 3-year period—1 year prior to and 2 years after the onset of the COVID-19 pandemic—for VA patients with chronic low-back pain. Results indicate that, despite disruptions to health care, opioid prescriptions and doses decreased over the entire observation period.
• Munk, N., Daggy, J. K., Slaven, J. E., Evans, E., Foote, T., Laws, B. V., Matthias, M. S., & Bair, M. J. (2024). Care ally-assisted massage for Veterans with chronic neck pain: TOMCATT results. Contemporary Clinical Trials, 142(Issue). doi:10.1016/j.cct.2024.107561
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  Purpose: Chronic neck pain (CNP) is prevalent and challenging to treat. Despite evidence of massage's effectiveness for CNP, multiple accessibility barriers exist. The Trial Outcomes for Massage: Care Ally-Assisted vs. Therapist Treated (TOMCATT) study examined a care ally-assisted massage (CA-M) approach compared to a waitlist control prior to a study design modification (WL-C0). Methods: CA-M consisted of in-person training for veteran/care-ally dyads to learn a standardized 30-minue massage routine, instructional DVD, and printed treatment manual. Participants were to complete three care ally-assisted massage sessions weekly for 12-weeks. Outcomes collected at baseline, 1-, 3-, and 6-months included validated measures of neck pain severity and associated disability. Linear mixed-model approaches were used for analysis with 3-months as the primary outcome timepoint. Results: Participants (N = 203) were 56.7 ± 14 years old, 75% White, 15% female, and 75% married/partnered. Among 102 CA-M participants, 45% did not attend the in-person training and subsequently withdrew from the study and were more likely to be younger (p =.016) and employed (p =.004). Compared to WL-C0, CA-M participants had statistically significant reductions in pain-related disability at 3-months (−3.4, 95%CI = [−5.8, −1.0]; p =.006) and 6-months (−4.6, 95%CI = [−7.0, −2.1]; p
• Shanahan, M. L., Rand, K. L., Galloway, A., & Matthias, M. S. (2024). Treatment Goals and Preferences of Black Veterans with Chronic Musculoskeletal Pain. Journal of Pain, 25(Issue 7). doi:10.1016/j.jpain.2024.02.001
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  Understanding patient goals and preferences is critical in the context of complex conditions such as chronic pain. This need may be especially pronounced for Black patients, who experience significant health and healthcare disparities. The primary aim of this study was to describe the treatment goals and preferences of Black veterans with chronic musculoskeletal pain who were enrolled in the intervention arm of a randomized controlled trial testing a coaching intervention. In the coaching sessions, participants (n = 106) identified their most important pain-related treatment goals and preferences. Participants’ top treatment goals were to improve physical functioning (61%), increase engagement in valued activities (45%), and reduce pain intensity (37%). Most participants (73%) preferred non-pharmacological treatments (eg, physical therapy, exercise, acupuncture, yoga). The 17% of participants who identified medications as a preferred treatment demonstrated higher levels of depression and anxiety compared to those who did not. Approximately 42% and 21% of participants stated a preference to avoid pharmacological and surgical pain treatments, respectively. Black patients with chronic pain prioritize improving physical functioning and pain intensity in service of increasing their engagement in exercise, work, relationships, and leisure activities. Also, in the current study, patients expressed a clear preference for non-pharmacological pain treatments. Future research should investigate ways to improve communication of goals and preferences with providers and facilitate access to non-pharmacological treatments for Black patients with chronic pain. Perspective: This article describes the treatment goals and preferences of Black veterans with chronic pain. Most patients prioritized goals to improve physical functioning, pain severity, and participation in valued activities. Patients primarily preferred non-pharmacological treatments. This emphasizes the need for clear communication with Black patients regarding pain-related goals and non-pharmacological treatment options.
• Eliacin, J., Burgess, D., Rollins, A. L., Patterson, S., Damush, T., Bair, M. J., Salyers, M. P., Spoont, M., Chinman, M., Slaven, J. E., & Matthias, M. S. (2023). Outcomes of a peer-led navigation program, PARTNER-MH, for racially minoritized Veterans receiving mental health services: A pilot randomized controlled trial to assess feasibility and acceptability. Translational Behavioral Medicine, 13(Issue 9). doi:10.1093/tbm/ibad027
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  This pilot study explored the feasibility and acceptability of PARTNER-MH, which aimed to engage racially diverse Veterans in mental health services, facilitate their active participation in care, and improve their communication with providers. Fifty participants were randomized to the intervention or a waitlist control group. For primary outcomes, we assessed the feasibility of the study design and PARTNER-MH's feasibility and acceptability. For secondary outcomes, we explored preliminary effects on patient engagement, patient activation, shared decision-making, and health-related outcomes. The study had a recruitment rate of 68%, enrollment rate of 91%, and a follow-up retention rate of 72%. For intervention feasibility and acceptability, fidelity scores were satisfactory and improved over time, session attendance was modest with 33% of participants completing ≥6 sessions, and 89% of participants were satisfied with the intervention. For secondary outcomes, patients in the intervention arm showed significant improvement on self-reported mental health and depression, compared with those in the control group at both 6- and 9-month follow-ups. However, there were no significant differences between study arms on the other measures. Pilot results provide support for future testing of PARTNER-MH in a larger trial, although modifications are needed to increase session attendance and follow-up retention rate.
• Eliacin, J., Matthias, M. S., Cameron, K. A., & Burgess, D. J. (2023). Veterans’ views of PARTNER-MH, a peer-led patient navigation intervention, to improve patient engagement in care and patient-clinician communication: A qualitative study. Patient Education and Counseling, 114(Issue). doi:10.1016/j.pec.2023.107847
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  Objective: In this study, we report on participants’ experiences of PARTNER-MH, a peer-led, patient-navigation intervention for racially and ethnically minoritized patients in Veterans Health Administration mental health services aimed at improving patient engagement in care and patient-clinician communication. Participants described their views of PARTNER-MH, barriers and facilitators to the intervention's implementation, and their application of varied intervention concepts to improve engagement in care and communication with their mental health clinicians. Methods: This is a qualitative analysis of the PARTNER-MH pilot randomized controlled trial. Participants participated in semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). Rapid data analysis approach was used to analyze the data. Results: Participants (n = 13) perceived PARTNER-MH as an acceptable intervention, and viewed use of peers as interventionists, long-term outreach and engagement efforts, and navigation services favorably. Barriers to implementation included limited flexibility in peers’ schedules and lack of peer/participant gender concordance, as well as limited options for program delivery modality. Three main themes summarized participants’ views and perceived benefits of PARTNER-MH that contributed to improved patient-clinician communication: 1) increased patient engagement, 2) improved patient-clinician relationship, and 3) enhanced communication self-efficacy. Conclusions: Participants viewed PARTNER-MH as beneficial and identified several intervention components that contributed to improved engagement in care, communication self-efficacy, and patient-clinician communication. Practice implication: Some patients, especially minoritized patients and those who have been disenfranchised from healthcare systems may benefit from peer-led interventions that facilitate engagement in care and communication self-efficacy to improve patient-clinician communication and healthcare outcomes. Trial registration: ClinicalTrials.gov NCT04515771.
• Eliacin, J., Patterson, S. M., Mendez, D. M., Burgess, D. J., Traylor, M. H., Borden, M. Y., Slaven, J. E., & Matthias, M. S. (2023). Findings from a Peer-Facilitated, Social Isolation Intervention in the Veterans Health Administration Healthcare System: A Mixed-Methods, Pilot Feasibility Study. Journal of General Internal Medicine, 38(Issue 16). doi:10.1007/s11606-023-08387-x
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  Background: Social isolation is a global public health threat. Veterans are particularly at risk for social isolation due to high rates of comorbid physical and mental health problems. Yet, effective interventions are limited. Objectives: Our primary objective was to assess the feasibility and acceptability of CONNECTED, a novel, transdiagnostic intervention to reduce social isolation that includes individual and group components and is delivered by peers via telehealth. Secondary objectives were to identify appropriate outcome measures and explore preliminary intervention effects. Methods: This was a two-phase study. In Phase 1, to evaluate study feasibility, we surveyed 200 veterans to assess prevalence of social isolation and their interest in social connectedness interventions. In Phase 2, we employed a mixed-methods, pre-post study design in which we piloted CONNECTED with 19 veterans through 2 successive cohorts to further assess feasibility, to evaluate acceptability, and to explore preliminary effectiveness. Quantitative analyses involved descriptive and bivariate analyses as well as multivariate modeling. Qualitative interviews were analyzed using thematic analysis. Results: For Phase 1, 39% of veterans surveyed were socially isolated. Participants who were ≤ 55 years old, caregivers, and those who experienced unmet social needs were more likely to report social isolation. Over 61% expressed interest in VA programs to reduce social isolation. For Phase 2, the pilot intervention, recruitment rate was 88% and the enrollment rate was 86%. Retention rates for the two cohorts were 80% and 50%, respectively, and satisfaction rates among intervention completers were 100%. Results also showed statistically significant improvements in social isolation (+ 5.91, SD = 4.99; p =.0028), social support (+ 0.74, SD = 1.09; p =.03), anxiety (-3.92, SD = 3.73; p =.003), and depression (-3.83, SD = 3.13; p =.001). Results for the other measures were not statistically significant. Conclusion: CONNECTED is a feasible and acceptable intervention and is likely to be an effective tool to intervene on social isolation among veterans.
• Matthias, M. S., Burgess, D. J., & Eliacin, J. (2023). Healthcare Access and Delivery During the COVID-19 Pandemic for Black Veterans with Chronic Pain: a Qualitative Study. Journal of General Internal Medicine, 38(Issue 4). doi:10.1007/s11606-022-07884-9
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  Background: The COVID-19 pandemic led to significant disruptions in healthcare and rapid increases in virtual healthcare delivery. The full effects of these shifts remain unknown. Understanding effects of these disruptions is particularly relevant for patients with chronic pain, which typically requires consistent engagement in treatment to maximize benefit, and for Black patients, given documented racial disparities in pain treatment and telehealth delivery. Objective: To understand how Black patients with chronic pain experienced pandemic-related changes in healthcare delivery. Design: In-depth, semi-structured qualitative interviews Participants: Black veterans with chronic pain. Key Results: Participants described decreased ability to self-manage their chronic pain, obtain nonpharmacological services such as physical therapy, see their primary care providers, and schedule surgery. Most did not believe telehealth met their needs, describing feeling inadequately assessed for their pain and noting that beyond renewing prescriptions, telehealth visits were not that useful. Some believed their communication with their providers suffered from a lack of in-person contact. Others, however, were willing to accept this tradeoff to prevent possible exposure to COVID-19, and some appreciated the convenience of being able to access healthcare from home. Conclusions: Black patients with chronic pain described mostly negative effects from the shift to telecare after the pandemic’s onset. Given existing disparities and likely persistence of virtual care, research on the longer-term effects of virtual pain care for Black patients is needed.
• Eliacin, J., Burgess, D. J., Rollins, A. L., Patterson, S., Damush, T., Bair, M. J., Salyers, M. P., Spoont, M., Slaven, J. E., O'Connor, C., Walker, K., Zou, D. S., Austin, E., Akins, J., Miller, J., Chinman, M., & Matthias, M. S. (2022). Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH), a Peer-Led Patient Navigation Intervention for Racially and Ethnically Minoritized Veterans in Veterans Health Administration Mental Health Services: Protocol for a Mixed Methods Randomized Controlled Feasibility Study. JMIR Research Protocols, 11(Issue 9). doi:10.2196/37712
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  Background: Mental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making. Objective: The primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research. Methods: This pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings. Results: Participants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex. Conclusions: Rather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals.
• Fettig, L., Tang, Q., Newton, E., Rosario, R., Matthias, M. S., & Torke, A. M. (2022). A Communication Skills Training Workshop to Improve ICU Team Relational Coordination about Goals of Care: A Pilot Study. American Journal of Hospice and Palliative Medicine, 39(Issue 10). doi:10.1177/10499091211069994
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  Background: Families of critically ill patients and their healthcare team must make life and death decisions together. Ideally, intensive care unit team members collaborate in the support of patients and families as goals of care are clarified and care plans are created. Few interventions exist to improve collaboration around this process. Team-based communication skills training about goals-of-care conversations represents one promising intervention. Objective: The purpose of this study was to examine the impact of a communication skills training workshop on coordination and collaboration among ICU team members. Design: Participants from a single institution completed surveys immediately before and six months after completion of the workshop. All participants, including nurses, physicians, social workers, and chaplains, completed a goals-of-care Relational Coordination survey. Nurses and physicians completed a Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (JSAPNC) survey. Results: Thirty-six participants were enrolled in three workshops. Seventeen and fifteen participants completed the relational coordination survey and JSAPNC respectively at both time points. The mean intergroup relational coordination index increased from 2.94 pre-intervention to 3.19 6-month post (P =.002, d=.89). Nurse relational coordination index ratings of all other groups increased from 2.84 pre-intervention to 3.08 6-month post (p =.004, d=1.23). Mean total scores on the JSAPNC survey did not change significantly from pre-intervention (53.8) to 6-month post (54.2, P =.45). Conclusion: Team-based communication skills training may improve ICU team relational coordination surrounding goals of care.
• Lee, J. L., Huffman, M., Rattray, N. A., Carnahan, J. L., Fortenberry, J. D., Fogel, J. M., Weiner, M., & Matthias, M. S. (2022). “I Don’t Want to Spend the Rest of my Life Only Going to a Gender Wellness Clinic”: Healthcare Experiences of Patients of a Comprehensive Transgender Clinic. Journal of General Internal Medicine, 37(Issue 13). doi:10.1007/s11606-022-07408-5
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  Background: Transgender individuals are less likely to have had a primary care visit in the last year than cisgender individuals. While the importance of multidisciplinary clinics for transgender care has been established, little is known about the healthcare experiences of transgender patients with these clinics. Objective: To describe how patients experience transgender clinics and how these experiences compare to those experiences in other settings. Participants: Twenty-one adult patients of a gender health program. Design and Approach: Semi-structured interviews of transgender patients. The interviews focused on two domains: healthcare experiences and relationships with healthcare providers. Key Results: Overall, transgender patients expressed a need for healthcare services, particularly for primary care, that are partially met by the comprehensive care clinic model. Limitations in access included the lack of willing providers, where the patients live, and long wait times for appointments. Participants recounted a range of experiences, both positive and negative, with providers outside of the transgender clinic, but only positive experiences to share about providers from the transgender clinic. Conclusion: Outside specialty transgender settings, many patients had negative experiences with providers who were unwilling or unable to provide care. This study speaks to the need for primary care providers who can and will treat transgender patients, as well as the need for healthcare spaces that feel safe to transgender patents.
• Lee, J. L., Kara, A., Huffman, M., Matthias, M. S., Radecki, B., Savoy, A., Schaffer, J. T., & Weiner, M. (2022). Qualitative Analysis of Team Communication with a Clinical Texting System at a Midwestern Academic Hospital. Applied Clinical Informatics, 13(Issue 2). doi:10.1055/s-0042-1744389
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  Background Hospitals are increasingly replacing pagers with clinical texting systems that allow users to use smartphones to send messages while maintaining compliance for privacy and security. As more institutions adopt such systems, the need to understand the impact of such transitions on team communication becomes ever more significant. Methods We conducted focus groups with hospitalists and individual interviews with nurses at one academic medical center in the Midwest. All interviews and focus groups were audiorecorded, transcribed, and deidentified for analysis. All transcripts and notes were independently read by two members of the research team and coded for themes. Results Twenty-one hospitalists and eight nurses participated in the study. Although study participants spoke favorably of texting, they identified more dissatisfactions with texting than benefits. There were disagreements regarding appropriate texting practices both within and between the hospitalists and nurses. Conclusion Despite the benefits of texting, there is room for improving team communication and understanding in the realm of clinical texting. A lack of shared understanding regarding when and how to use texting may require long-term solutions that address teamwork and appropriateness.
• Matthias, M. S., & Henry, S. G. (2022). Reducing Frustration and Improving Management of Chronic Pain in Primary Care: Is Shared Decision-making Sufficient?. Journal of General Internal Medicine, 37(Issue 1). doi:10.1007/s11606-021-06967-3
• Matthias, M. S., Adams, J., Burgess, D. J., Daggy, J., Eliacin, J., Flores, P., Hirsh, A. T., Myers, L. J., Perkins, A. J., Menen, T., Procento, P., Rand, K. L., Salyers, M. P., Shanahan, M. L., & Bair, M. J. (2022). Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics. Contemporary Clinical Trials, 118(Issue). doi:10.1016/j.cct.2022.106790
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  Background: Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain. Methods: In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning. Discussion: Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care. Trial Registration: clinicaltrials.gov, # NCT03562793.
• Matthias, M. S., Adams, J., Burgess, D. J., Daggy, J., Gowan, T. M., Perkins, A. J., & Eliacin, J. (2022). Effects of the COVID-19 Pandemic on Black Veterans’ Mental Health: A Qualitative Investigation. Journal of Health Care for the Poor and Underserved, 33(Issue 3). doi:10.1353/hpu.2022.0112
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  Although the disproportionate effects of the COVID-19 pandemic on Black Americans are well-documented, we know little about its effects on their day-to-day lives and sense of wellbeing, especially for those who have served in the military. We conducted qualitative interviews with 21 Black veterans to understand their experiences with the pandemic and administered questionnaires about mental health and pandemic impact. Questionnaires indicated mild depression, moderate anxiety and loneliness, and pandemic effects on social support and health care. Interviews revealed that heightened anxiety and stress were driven by not trusting others to take the pandemic seriously, workplace anxiety, comorbidities, and the pandemic’s pronounced effects on Black communities. Participants shared insights into these effects, including lack of caution on the part of some and the role of systemic racism. Findings enhance our understanding of how Black veterans have experienced the pandemic and may have important implications for other underserved groups.
• Matthias, M. S., Hirsh, A. T., Ofner, S., & Daggy, J. (2022). Exploring the Relationships Among Social Support, Patient Activation, and Pain-Related Outcomes. Pain Medicine (United States), 23(Issue 4). doi:10.1093/pm/pnab306
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  Objective: Social support has been linked to more effective pain adaptation. The relationship between social support and other relevant constructs is less well understood. Chief among these is patient activation, which has robust links to effective self-management, yet has not been well studied in chronic pain. We sought to better understand these relationships in an effort to inform future intervention strategies for patients with chronic pain. Methods: Using baseline data from a clinical trial with patients with chronic pain (N = 213), we analyzed the relationships among perceived social support and patient activation, depression, anxiety, general health perceptions, pain centrality, pain catastrophizing, and pain intensity and interference. Multiple linear regression was used to examine the effect of social support on outcomes. Patient activation was explored as a mediator of the effect of social support on outcomes. Results: Social support was significantly associated with all outcomes except pain. Social support explained the greatest variance in patient activation (squared semi-partial correlation = 0.081), followed by depression (0.073) and general health perceptions (0.072). Patient activation was not found to be a significant mediator of the effect of social support on pain-related outcomes. Conclusions: These findings provide insight into the roles of patient activation and social support in chronic pain management. Although patient activation did not mediate the relationship between social support and outcomes, this study is an important step toward gaining a more complete understanding of constructs thought to be related to pain self-management and points to the need to advance theory in this area to guide future research. Such work is needed to optimize interventions for patients with chronic pain.
• Munk, N., Daggy, J. K., Evans, E., Kline, M., Slaven, J. E., Laws, B., Foote, T., Matthias, M. S., & Bair, M. J. (2022). Therapist-Delivered Versus Care Ally-Assisted Massage for Veterans With Chronic Neck Pain: Protocol for a Randomized Controlled Trial. JMIR Research Protocols, 11(Issue 9). doi:10.2196/38950
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  Background: Chronic neck pain (CNP) is prevalent, and it reduces functional status and quality of life and is associated with deleterious psychological outcomes in affected individuals. Despite the desirability of massage and its demonstrated effectiveness in CNP treatment, multiple accessibility barriers exist. Caregiver-applied massage has demonstrated feasibility in various populations but has not been examined in Veterans with CNP or compared in parallel to therapist-delivered massage. Objective: This manuscript described the original study design, lessons learned, and resultant design modifications for the Trial Outcomes for Massage: Care Ally-Assisted Versus Therapist-Treated (TOMCATT) study. Methods: TOMCATT began as a 3-arm, randomized controlled trial of 2 massage delivery approaches for Veterans with CNP with measures collected at baseline, 1 and 3 months after intervention, and 6 months (follow-up). Arm I, care ally-assisted massage, consisted of an in-person, 3.5-hour training workshop, an instructional DVD, a printed treatment manual, and three 30-minute at-home care ally-assisted massage sessions weekly for 3 months. Arm II, therapist-treated massage, consisted of two 60-minute sessions tailored to individual pain experiences and treatments per week for 3 months. The treatments followed a standardized Swedish massage approach. Arm III consisted of wait-list control. Results: Retention and engagement challenges in the first 30 months were significant in the care ally-assisted massage study arm (63% attrition between randomization and treatment initiation) and prompted modification to a 2-arm trial, that is, removing arm I. Conclusions: The modified TOMCATT study successfully launched and exceeded recruitment goals 2.5 months before the necessary COVID-19 pause and is expected to be completed by early 2023.
• Robles, M., Robles, M., Mortazavi, L., Mortazavi, L., Vannerson, J., Vannerson, J., Matthias, M. S., & Matthias, M. S. (2022). How a Medication for Opioid Use Disorder Curriculum Translates into Experiences and Internal Medicine Residents’ Understanding of Patients with Opioid Use Disorder. Teaching and Learning in Medicine, 34(Issue 5). doi:10.1080/10401334.2021.1897597
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  Problem: The number of people with an Opioid Use Disorder (OUD) continues to outpace access to associated medication. Ninety-six percent of states report higher rates of OUD than access to medications, and, despite being the standard of care, only 3% of physicians currently prescribe medication for opioid use disorder (MOUD). Prior studies have shown that decreasing barriers, such as a lack of knowledge about MOUD, increased physicians’ willingness to prescribe. However, most internal medicine residency programs do not have a required addiction curriculum. As a result, we created a curriculum and conducted qualitative interviews with residents to better understand experiences with the curriculum. Intervention: In an effort to overcome physician-centered barriers associated with prescribing MOUD, we developed and implemented a week-long curriculum, Addiction Week, for second and third year Internal Medicine Residents at Indiana University School of Medicine in a safety-net clinic. The curriculum included the following: didactics on substance use disorder (SUD), including OUD and alcohol use disorder, and MOUD (mostly buprenorphine), and mostly web-based, peer-reviewed and guideline based readings about addiction, direct observation of addiction counselors, direct discussion with people receiving MOUD, observation of a group therapy session, informal discussion with providers who prescribe MOUD, and, for some residents, observation of a physician prescribing MOUD. After completing the curriculum, the residents participated in an hour long audio-recorded interview to better understand their experiences with the curriculum. Context: This study was completed at a residency program where residents were not previously exposed to outpatient MOUD prescribing. Due to limited availability of faculty treating patients with MOUD, residents spent the majority of their time shadowing a social worker. Impact: Residents described gaining a deeper understanding of OUD by having the opportunity to interact with patients in a stable outpatient setting, which for many led to increased confidence and willingness to prescribe MOUD for people with OUD. Lessons learned: The greater understanding of addiction and willingness to prescribe MOUD described by residents in this study indicate that this type of curriculum may be a promising way to increase MOUD prescribing. Further studies are needed to evaluate whether this intervention can change prescribing behaviors. Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1897597.
• Eliacin, J., Matthias, M. S., Burgess, D. J., Patterson, S., Damush, T., Pratt-Chapman, M., McGovern, M., Chinman, M., Talib, T., O’Connor, C., & Rollins, A. (2021). Pre-implementation Evaluation of PARTNER-MH: A Mental Healthcare Disparity Intervention for Minority Veterans in the VHA. Administration and Policy in Mental Health and Mental Health Services Research, 48(Issue 1). doi:10.1007/s10488-020-01048-9
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  To design PARTNER-MH, a peer-led, patient navigation program for implementation in Veterans Health Administration (VHA) mental health care settings, we conducted a pre-implementation evaluation during intervention development to assess stakeholders’ views of the intervention and to explore implementation factors critical to its future adoption. This is a convergent mixed-methods study that involved qualitative semi-structured interviews and survey data. Data collection was guided by the Consolidated Framework for Implementation Research (CFIR). We interviewed and administered the surveys to 23 peers and 10 supervisors from 12 midwestern VHA facilities. We used deductive and inductive approaches to analyze the qualitative data. We also conducted descriptive analysis and Fisher Exact Test to compare peers and supervisors’ survey responses. We triangulated findings to refine the intervention. Overall, participants viewed PARTNER-MH favorably. However, they saw the intervention’s focus on minority Veterans and social determinants of health framework as potential barriers, believing this could negatively affect the packaging of the intervention, complicate its delivery process, and impact its adoption. They also viewed clinic structures, available resources, and learning climate as potential barriers. Peers and supervisors’ selections and discussions of CFIR items were similar. Our findings informed PARTNER-MH development and helped identify factors that could impact its implementation. This project is responsive to the increasing recognition of the need to incorporate implementation science in healthcare disparities research. Understanding the resistance to the intervention’s focus on minority Veterans and the potential barriers presented by contextual factors positions us to adjust the intervention prior to testing, in an effort to maximize implementation success.
• McGuire, A., Matthias, M. S., Kukla, M., Henry, N., Carter, J., Flanagan, M., Bair, M. J., & Murphy, J. L. (2021). A National Survey of Patient Completion of Cognitive Behavioral Therapy for Chronic Pain: The Role of Therapist Characteristics, Attempt Rates, and Modification. Professional Psychology: Research and Practice, 52(Issue 6). doi:10.1037/pro0000399
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  The implementation of evidence-based psychotherapies, including patient-level measures such as penetration and rates of successfully completing a course of therapy, has received increasing attention. While much attention has been paid to the effect of patient-level factors on implementation, relatively little attention has been paid to therapist factors (e.g., professional training, experience). The present study explores therapists’ decisions to offer a particular evidence-based psychotherapy (Cognitive-behavioral therapy for chronic pain [CBT-CP]), whether and how they modify CBT-CP, and the relationship between these decisions and patient completion rates. The study utilized survey responses from 141 Veterans Affairs therapists certified in CBT-CP. Therapists reported attempting CBT-CP with a little less than one half of their patients with chronic pain (M = 48.8%, SD = 35.7). Therapist were generally split between reporting modifying CBT-CP for either very few or most of their patients. After controlling for therapist characteristics and modification, therapist-reported percentage of patients with attempted CBT-CP was positively associated with completion rates, t(111) = 4.57, p
• Shue, S., Matthias, M. S., Watson, D. P., Miller, K. K., & Munk, N. (2021). The career transition experiences of military Veterans: A qualitative study. Military Psychology, 33(Issue 6). doi:10.1080/08995605.2021.1962175
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  Transitioning out of a military career can be difficult and stressful for Veterans. The purpose of this study was to gain an in-depth understanding of the challenges and needs of career transitioning Veterans. Fifteen United States Veterans from a larger mixed methods research project completed a qualitative semi-structured interview regarding their career transition. Interview questions invited participants to define their transition experience, identify influential psychosocial factors, resources utilized or needed, what it meant to transition out of the military, role changes experienced, and how the participant had adapted to the transition. Emergent thematic analysis revealed 4 themes: 1) it is necessary to actively prepare for the transition; 2) a variety of factors impacted the military career transition process; 3) transitioning out of a military career equated to the loss of structure; and 4) the transition required Veterans to establish themselves outside of the military. Findings from this study identified barriers, desired assistance, and facilitators to the career transition process, which should be considered by those assisting transitioning Veterans and when developing transition-related resources. Continuing to expand on this knowledge will positively impact service members as they exit their military career.
• Burgess, D. J., Evans, R., Allen, K. D., Bangerter, A., Bronfort, G., Cross, L. J., Ferguson, J. E., Haley, A., Hagel Campbell, E. M., Mahaffey, M. R., Matthias, M. S., Meis, L. A., Polusny, M. A., Greg Serpa, J., Taylor, S. L., & Taylor, B. C. (2020). Learning to Apply Mindfulness to Pain (LAMP): Design for a pragmatic clinical trial of two mindfulness-based interventions for chronic pain. Pain Medicine (United States), 21(Issue). doi:10.1093/pm/pnaa337
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  Background. Mindfulness-based interventions (MBIs) are evidence-based nonpharmacological treatments for treating chronic pain. However, the predominant MBI, mindfulness-based stress reduction, has features that pose significant implementation barriers. Objectives. This study will test two approaches to delivering MBIs for improving Veterans' chronic pain and mental health comorbidities. These two approaches address key implementation barriers. Methods. We will conduct a four-site, three-arm pragmatic randomized controlled trial, Learning to Apply Mindfulness to Pain (LAMP), to test the effectiveness of two MBIs at improving pain and mental health comorbidities. Mobile Group LAMP consists of prerecordedmodules presented by amindfulness instructor that are viewed in an online group setting and interspersed with discussions led by a facilitator. Mobile LAMP consists of the same prerecorded modules but does not include a group component. We will test whether either of these MBIs will be more effective than usual care at improving chronic pain and whether the Mobile Group LAMP will be more effective than Mobile LAMP at improving chronic pain. Comparisons for the primary hypotheses will be conducted with continuous outcomes (Brief Pain Inventory interference score) repeated at 10 weeks, 6months, and 12months. The secondary hypotheses are that Mobile Group LAMP and Mobile LAMP will be more effective than usual care at improving secondary outcomes (e.g., post-traumatic stress disorder, depression). We will also confirm the comparisons for the primary and secondary hypotheses in gender-specific strata. Implications. This trial is expected to result in two approaches for delivering MBIs that will optimize engagement, adherence, and sustainability and be able to reach large numbers of Veterans.
• Eliacin, J., Matthias, M. S., Cunningham, B., & Burgess, D. J. (2020). Veterans’ perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication. Patient Education and Counseling, 103(Issue 9). doi:10.1016/j.pec.2020.03.017
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  Objectives: Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication. Methods: We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach. Results: Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers’ fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication. Conclusion: Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans. Practice Implications: We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers’ burnout.
• Lee, J. L., Williams, C. E., Baird, S., Matthias, M. S., & Weiner, M. (2020). Too Many Don’ts and Not Enough Do’s? A Survey of Hospitals About Their Portal Instructions for Patients. Journal of General Internal Medicine, 35(Issue 4). doi:10.1007/s11606-019-05528-z
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  Background: Patient portals present the opportunity to expand patients’ access to their clinicians and health information. Yet patients and clinicians have expressed the need for more guidance on portal and secure messaging procedures to avoid misuse. Little information is currently available concerning whether and how expectations of portal and messaging usage are communicated to patients. Objective: To identify the information made available to patients about patient portal use, and to assess ease in accessing such information. Design: A national survey of publicly available portal information from hospital websites. The study team followed up with phone calls to each hospital to request any additional patient-directed materials (e.g., pamphlets) not located in the web search. Participants: A random sample of 200 acute-care hospitals, 50 from each of four US Census regions, selected from the US Centers for Medicare & Medicaid Hospital Compare dataset. Main Measures: Availability of patient portals, secure messaging, and related functionality; the content and ease of access to patient-directed information about portals. Key Results: Of the hospitals sampled, 177 (89%) had a patient portal; 116 (66%) of these included secure messaging functionality. Most portals with secure messaging (N = 65, 58%) did not describe appropriate patient messaging conduct. Although many included disclaimers that the service is not for emergencies, 23 hospitals only included this within the fine prints of their “Terms and Conditions” section. Content analysis of additional patient-directed materials revealed a focus on logistical content, features of the portals, and parameters of use. Of the three categories, logistical content (e.g., creating an account) was the most thorough. Conclusions: Although most of the sampled hospitals had patient portals, many fail to educate patients fully and set expectations for secure messaging. To improve patient engagement and minimize harm, hospitals and clinicians need to provide more information and set clearer guidelines for patients.
• Matthias, M. S. (2020). Opioid Tapering and the Patient-Provider Relationship. Journal of General Internal Medicine, 35(Issue 1). doi:10.1007/s11606-019-05337-4
• Matthias, M. S., & Imperiale, T. F. (2020). A risk prediction tool for colorectal cancer screening: A qualitative study of patient and provider facilitators and barriers. BMC Family Practice, 21(Issue 1). doi:10.1186/s12875-020-01113-0
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  Background: Despite proven effectiveness of colorectal cancer (CRC) screening, at least 35% of screen-eligible adults are not current with screening. Decision aids and risk prediction tools may help increase uptake, adherence, and efficiency of CRC screening by presenting lower-risk patients with options less invasive than colonoscopy. The purpose of this qualitative study was to determine patient and provider perceptions of facilitators and barriers to use of a risk prediction tool for advanced colorectal neoplasia (CRC and advanced, precancerous polyps), to maximize its chances of successful clinical implementation. Methods: We conducted qualitative, semi-structured interviews with patients aged 50-75 years who were not current with CRC screening, and primary care providers (PCPs) at an academic and a U.S. Department of Veterans Affairs Medical Center in the Midwest from October 2016 through March 2017. Participants were asked about their current experiences discussing CRC screening, then were shown the risk tool and asked about its acceptability, barriers, facilitators, and whether they would use it to guide their choice of a screening test. The constant comparative method guided analysis. Results: Thirty patients and PCPs participated. Among facilitators were the tool's potential to increase screening uptake, reduce patient risk, improve resource allocation, and facilitate discussion about CRC screening. PCP-identified barriers included concerns about the tool's accuracy, consistency with guidelines, and time constraints. Conclusions: Patients and PCPs found the risk prediction tool useful, with potential to increase uptake, safety, and efficiency of CRC screening, indicating potential acceptability and feasibility of implementation into clinical practice.
• Matthias, M. S., Bair, M. J., Ofner, S., Heisler, M., Kukla, M., McGuire, A. B., Adams, J., Kempf, C., Pierce, E., Menen, T., McCalley, S., Johnson, N. L., & Daggy, J. (2020). Peer Support for Self-Management of Chronic Pain: the Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE) Trial. Journal of General Internal Medicine, 35(Issue 12). doi:10.1007/s11606-020-06007-6
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  Background: Pain self-management is an effective, evidence-based treatment for chronic pain. Peer support, in which patients serve as coaches for other patients, has been effective in other chronic conditions and is a potentially promising approach to implementing pain self-management programs using fewer clinical resources. Objective: To test a peer coach-delivered pain self-management program for chronic pain. Design: Randomized controlled trial. Participants: Veterans with chronic musculoskeletal pain. Intervention: Intervention patients were assigned a trained peer coach for 6 months. Coaches, who were volunteers, were asked to contact their assigned patients, either by phone or in person, twice per month. Coaches and patients were given an intervention manual to guide sessions. The control group was offered a 2-hour pain self-management class. Main Measures: The primary outcome was total pain, assessed by the Brief Pain Inventory (BPI). Secondary outcomes were anxiety, depression, pain catastrophizing, self-efficacy, social support, patient activation, health-related quality of life, and healthcare utilization. Outcomes were measured at baseline, 6 months, and 9 months. Key Results: Two hundred fifteen patients enrolled (120 intervention, 95 control). Adherence to intervention protocol was low, with only 13% of patients reporting having at least the recommended 12 peer coach meetings over the 6-month intervention. BPI total decreased from baseline to 6 months and baseline to 9 months in both groups. At 9 months, this change was statistically significant (intervention, − 0.40, p = 0.018; control, − 0.47, p = 0.006). There was not a statistically significant difference between groups on BPI at either time point. No secondary outcomes improved significantly in either group after adjusting for multiple comparisons. Conclusions: Patients randomized to peer support did not differ from control patients on primary and secondary outcomes. Other peer support models that do not rely on volunteers might be more effective. Trial Registration: ClinicalTrials.gov Identifier: NCT02380690
• Matthias, M. S., Daggy, J., Ofner, S., McGuire, A. B., Kukla, M., & Bair, M. J. (2020). Exploring peer coaches’ outcomes: Findings from a clinical trial of patients with chronic pain. Patient Education and Counseling, 103(Issue 7). doi:10.1016/j.pec.2020.02.007
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  Objective: Although peer coaching can help patients manage chronic conditions, few studies have evaluated the effects of peer coaching on coaches, and no studies have systematically examined these effects in the context of chronic pain coaching. Methods: Peer coach outcomes were assessed as part of a randomized trial of peer coaching for chronic pain. In this exploratory analysis, linear mixed models were used to evaluate changes in peer coaches’ pain and related outcomes from baseline to 6 and 9 months. The Šidák method was used to account for multiple comparisons. Results: Peer coaches (N = 55) experienced statistically significant increases in anxiety and pain catastrophizing from baseline to 6 months, which were no longer significant after adjustment. All other changes were not statistically significant. Conclusions: Despite prior studies suggesting that peer coaches benefit from serving as a coach, the current study failed to support that conclusion. Practice Implications: Peer coaching remains a promising model, with high potential for implementation, for a number of chronic conditions requiring self-management. However, to maximize the benefits of such interventions, it is essential to monitor both those being coached and the coaches themselves, and not to assume that serving as a coach is inherently beneficial.
• Matthias, M. S., Evans, E., Porter, B., McCalley, S., & Kroenke, K. (2020). Patients’ Experiences with Telecare for Chronic Pain and Mood Symptoms: A Qualitative Study. Pain Medicine (United States), 21(Issue 10). doi:10.1093/pm/pnz345
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  Objective. Pain, anxiety, and depression commonly co-occur, can have reciprocal effects, and are associated with substantial disability and health care costs. However, few interventions target treatment of pain and mood disorders as a whole. The Comprehensive vs. Assisted Management of Mood and Pain Symptoms (CAMMPS) trial was a randomized trial comparing two pragmatic telecare interventions, a high- vs low-resource approach to pain and anxiety/depression treatment. The purpose of the current study is to better understand patients’ perspectives on both intervention approaches, including intervention components, delivery, patient experiences, and patient outcomes. Design. Qualitative, semistructured interviews. Setting. A Veterans Affairs Medical Center. Subjects. Twenty-five patients were purposefully sampled from both study arms. Methods. Patients were interviewed about their experiences with pain and mood treatment, perceived benefits and changes, and experiences with the intervention model to which they were randomized. The constant comparison method guided analysis. Results. Pain was more important than mood for most participants. Participants described developing increased awareness of their symptoms, including connecting pain and mood, which enabled better management. Participants in the high-resource intervention described the added value of the study nurse in their symptom management. Conclusions. Patients in a telecare intervention for chronic pain and mood symptoms learned to connect pain and mood and be more aware of their symptoms, enabling more effective symptom management. Patients in the high-resource intervention described the added benefits of a nurse who provided informational and motivational support. Implications for tradeoffs between resource intensity and patient outcomes are discussed.
• Matthias, M. S., Huffman, M., Frankel, R. M., Weiner, M., & Lee, J. L. (2020). Insecure messaging: How clinicians approach potentially problematic messages from patients. JAMIA Open, 3(Issue 4). doi:10.1093/jamiaopen/ooaa051
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  Objective: Secure messaging has become an integrated function of patient portals, but misuse of secure messaging by both patients and clinicians can lead to miscommunication and errors, such as overlooked urgent messages. We sought to uncover variations in clinician approaches and responses to messaging with patients. Methods: In this two-part study, 20 primary care clinicians (1) composed message responses to five hypothetical patient vignettes and messages and (2) were subsequently interviewed for their perspectives on appropriate circumstances for secure messaging. Messages and interviews were analyzed for themes. Results: Clinicians have different experiences with, and perceptions of, secure messaging. The messages the clinicians wrote were uniformly respectful, but differed in degrees of patient-centeredness and level of detail. None of the clinicians found their messaging workload to be unmanageable. From the interviews, we found divergent clinician perspectives about when to use secure messaging and how to respond to emotional content. Conclusion: Clinicians have different opinions about the appropriateness of secure messaging in response to specific medical issues. Our results noted a desire and need for greater guidance about secure messaging. This aspect of informatics education warrants greater attention in clinical practice. Practical implications: We summarize the types of issues raised by the participants yet to be addressed by existing guidelines. Further guidance from hospitals, professional societies, and other institutions that govern clinician behavior on the appropriateness and effectiveness of delivering care through secure messaging may aid clinicians and patients.
• Matthias, M. S., Talib, T. L., & Huffman, M. A. (2020). Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making?. Health Communication, 35(Issue 10). doi:10.1080/10410236.2019.1625000
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  Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan’s SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.
• Myers, A. L., & Matthias, M. S. (2020). Nursing facility residents’ cardiopulmonary resuscitation decisions. International Journal of Older People Nursing, 15(Issue 4). doi:10.1111/opn.12344
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  Context: As many as one-quarter of all residents in nursing facilities have cardiopulmonary resuscitation (CPR) as a documented choice in the medical record, despite the likelihood of limited medical benefit in this setting. Objectives: The aim of this study was to understand the perspectives of healthcare providers and nursing facility residents regarding CPR decisions. Methods: We used qualitative interviews to examine the perspectives of residents with a documented decision for CPR in the medical record. We then compared residents’ views with those of healthcare providers who routinely conduct advance care planning (ACP) conversations in the nursing facility setting. Results: Five themes emerged from the interviews: (a) Resident versus Provider Concerns, (b) Offering Information versus Avoidance, (c) Lack of Understanding of CPR, (d) Lack of Awareness, and (e) ‘Don't Keep Me on Machines'. Residents held misconceptions about CPR and/or exhibited an overall poor understanding of the relationship between their own health status and the likelihood of a successful CPR attempt. Although healthcare providers offer information and health education in an attempt to address knowledge gaps, these efforts are not always successful or even accepted by residents. Resident viewpoints and priorities differed from healthcare providers in ways that affected communication about CPR. Conclusions: Unrecognised differences in perceptions between providers and residents affect key aspects of ACP communication that can impact CPR decision-making. The concerns and priorities of institutionalized older adults may differ from those of healthcare providers, creating challenges for engaging some residents in ACP. Implications for Practice: ACP communication models and training should be designed not only to explore nursing facility residents' goals, values, and preferences, but also to elicit any underlying differences in perceptions that may affect communication. Healthcare providers can identifying the primary concerns of residents and assist them with integrating or reframing these issues as a part of ACP discussions.
• Seal, K. H., Becker, W. C., Murphy, J. L., Purcell, N., Denneson, L. M., Morasco, B. J., Martin, A. M., Reddy, K., van Iseghem, T., Krebs, E. E., Painter, J. M., Hagedorn, H., Pyne, J. M., Hixon, J., Maguen, S., Neylan, T. C., Borsari, B., DeRonne, B., Gibson, C., , Matthias, M. S., et al. (2020). Whole health options and pain education (WHOPE): A pragmatic trial comparing whole health team vs primary care group education to promote nonpharmacological strategies to improve pain, functioning, and quality of life in veterans-rationale, methods, and implementation. Pain Medicine (United States), 21(Issue). doi:10.1093/pm/pnaa366
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  Background. The Whole Health model of the U.S. Department of Veterans Affairs (VA) emphasizes holistic self-care and multimodal approaches to improve pain, functioning, and quality of life. wHOPE (Whole Health Options and Pain Education) seeks to be the first multisite pragmatic trial to establish evidence for the VA Whole Health model for chronic pain care. Design. wHOPE is a pragmatic randomized controlled trial comparing a Whole Health Team (WHT) approach to Primary Care Group Education (PC-GE); both will be compared to Usual VA Primary Care (UPC). The WHT consists of a medical provider, a complementary and integrative health (CIH) provider, and a Whole Health coach, who collaborate with VA patients to create a Personalized Health Plan emphasizing CIH approaches to chronic pain management. The active comparator, PC-GE, is adapted group cognitive behavioral therapy for chronic pain. The first aim is to test whether the WHT approach is superior to PC-GE and whether both are superior to UPC in decreasing pain interference in functioning in 750 veterans with moderate to severe chronic pain (primary outcome). Secondary outcomes include changes in pain severity, quality of life, mental health symptoms, and use of nonpharmacological and pharmacological therapies for pain. Outcomes will be collected from the VA electronic health record and patient-reported data over 12 months of follow-up. Aim 2 consists of an implementation-focused process evaluation and budget impact analysis. Summary. This trial is part of the Pain Management Collaboratory, which seeks to create national-level infrastructure to support evidence-based nonpharmacological pain management approaches for veterans and military service personnel.
• Shue, S., Brosmer, J., & Matthias, M. S. (2020). Reducing veterans' risk for suicidal behaviors: A qualitative study to inform development of the RECLAIM health promotion program. BMC Health Services Research, 20(Issue 1). doi:10.1186/s12913-020-05587-7
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  Background: In an effort to reduce the high rate of suicide among post-9/11 veterans, a collaborative team within the Department of Veterans Affairs (VA) has developed a holistic community-based health promotion program designed to facilitate social and self-connectedness. The purpose of this study was to elicit veteran and stakeholder feedback to prepare the program for piloting and implementation. Methods: Focus groups and interviews were conducted with post-9/11 veterans and veteran stakeholders (e.g., VA clinicians) to elicit feedback regarding the health promotion program. Focus groups and interviews were audio-recorded and transcribed. Qualitative thematic analysis identified key themes emerging from the focus groups and interviews. Results: Seven focus groups (3 Veteran groups, 4 stakeholder groups) and 3 interviews (2 Veterans, 1 stakeholder) were conducted with 41 participants (14 veterans, 27 stakeholders). Overall, participants had a positive perception of the program. Thematic analysis revealed shared perspectives that provided insight into 1) enhancing program recruitment and retention, 2) the perceived ability of a health promotion program to provide more holistic, veteran-centered care, and 3) using health promotion programs to help veterans establish structure in their daily lives. Conclusions: Findings indicated an overall acceptance of the program, and participants' perspectives on how to reduce barriers and enhance facilitators can inform the development of a larger-scale health promotion program that can be tested through future research. While discussion questions were specifically focused on the program in this study, findings can be considered more broadly for the design and implementation of related programs to effectively improve the health and wellness of post-9/11 veterans.
• Kroenke, K., Baye, F., Lourens, S. G., Evans, E., Weitlauf, S., McCalley, S., Porter, B., Matthias, M. S., & Bair, M. J. (2019). Automated Self-management (ASM) vs. ASM-Enhanced Collaborative Care for Chronic Pain and Mood Symptoms: the CAMMPS Randomized Clinical Trial. Journal of General Internal Medicine, 34(Issue 9). doi:10.1007/s11606-019-05121-4
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  Background: Chronic musculoskeletal pain is often accompanied by depression or anxiety wherein co-occurring pain and mood symptoms can be more difficult to treat than either alone. However, few clinical trials have examined interventions that simultaneously target both pain and mood conditions. Objective: To determine the comparative effectiveness of automated self-management (ASM) vs. ASM-enhanced collaborative care. Design: Randomized clinical trial conducted in six primary care clinics in a VA medical center. Participants: Two hundred ninety-four patients with chronic musculoskeletal pain of at least moderate intensity and clinically significant depressive and/or anxiety symptoms. Intervention: ASM consisted of automated monitoring and 9 web-based self-management modules. Comprehensive symptom management (CSM) combined ASM with collaborative care management by a nurse-physician team. Both interventions were delivered for 12 months. Main Measures: Primary outcome was a composite pain-anxiety-depression (PAD) z-score consisting of the mean of the BPI, PHQ-9, and GAD-7 z-scores: 0.2, 0.5, and 0.8 represent potentially small, moderate, and large clinical differences. Secondary outcomes included global improvement, health-related quality of life, treatment satisfaction, and health services use. Key Results: Both CSM and ASM groups had moderate PAD score improvement at 12 months (z = − 0.65 and − 0.52, respectively). Compared to the ASM group, the CSM group had a − 0.23 (95% CI, − 0.38 to − 0.08; overall P =.003) greater decline in composite PAD z-score over 12 months. CSM patients were also more likely to report global improvement and less likely to report worsening at 6 (P =.004) and 12 months (P =.013). Conclusions: Two intervention models relying heavily on telecare delivery but differing in resource intensity both produced moderate improvements in pain and mood symptoms. However, the model combining collaborative care led by a nurse-physician team with web-based self-management was superior to self-management alone. Trial Registration: ClinicalTrials.gov: NCT0175730.
• Matthias, M. S., Daggy, J., Adams, J., Menen, T., McCalley, S., Kukla, M., McGuire, A. B., Ofner, S., Pierce, E., Kempf, C., Heisler, M., & Bair, M. J. (2019). Evaluation of a peer coach-led intervention to improve pain symptoms (ECLIPSE): Rationale, study design, methods, and sample characteristics. Contemporary Clinical Trials, 81(Issue). doi:10.1016/j.cct.2019.04.002
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  Chronic pain is prevalent, costly, and a leading cause of disability. Pain self-management (i.e., employing self-management strategies including behavioral modifications) is an effective, evidence-based treatment. However, implementation and delivery of a pain self-management model is challenging because of time and resources. Peer supported pain self-management offers a promising approach to implementing pain self-management programs using fewer clinical resources. Evaluation of a Peer Coach-Led Intervention for the Improvement of Pain Symptoms (ECLIPSE) is a randomized controlled trial testing effectiveness of peer coach-delivered pain self-management intervention versus controls receiving a class on pain and pain self-management. ECLIPSE is a Hybrid Type 1 study testing effectiveness while examining implementation factors. ECLIPSE enrolled 215 veterans randomly assigned to the peer coaching (N = 120) or control (N = 95) arm. The peer coaching intervention lasts 6 months, with patient-peer coach pairs instructed to talk twice per month. Coaches attend initial training, are provided a detailed training manual, and attend monthly booster sessions. Outcomes are assessed at baseline, 6 months, and 9 months. The primary outcome is overall pain (intensity and interference), measured by the Brief Pain Inventory (BPI). Secondary outcomes are self-efficacy, social support, pain catastrophizing, patient activation, health-related quality of life, and health care utilization. To maximize implementation potential of pain self-management, innovative delivery methods are needed that do not require additional resources from healthcare teams. A novel and promising approach is a peer-coaching model, in which patients who are successfully managing their pain offer information, ongoing support, and advice to other patients with pain. Clinical Trials Registration: NCT02380690
• Shields, C. G., Fuzzell, L. N., Christ, S. L., & Matthias, M. S. (2019). Patient and provider characteristics associated with communication about opioids: An observational study. Patient Education and Counseling, 102(Issue 5). doi:10.1016/j.pec.2018.12.005
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  Objective: Our objective is to examine the relationship of patient and provider characteristics and communication with chronic non-cancer pain and opioid management in primary care. Method: We conducted an observational study using audio-recorded primary care appointments (up to 3/patient)and self-reported assessments of primary care providers (PCPs)and patients. We coded visit transcripts for 1)opioid and pain management talk and 2)mental health and opioid safety talk. Results: Eight PCPs and 30 patients had complete data for 78 clinic visits. PCPs and patients engaged in more opioid and pain management talk when patients reported greater pain catastrophizing and PCPs reported higher psychosocial orientation. PCPs and patients engaged in talk about mental health and opioid safety when patients reported greater anxiety, higher working alliance with their PCP, and when PCPs reported higher burnout. PCPs’ negative attitudes about opioids were associated with fewer discussions about mental health and opioid safety. Conclusions: Our results should facilitate design of interventions that improve communication and, ultimately, pain outcomes for patients. Practice Implications: Clinicians can use our results to increase patient engagement in discussions about opioid use and pain management or mental health and safety discussions.
• Shue, S. A., Mcguire, A. B., & Matthias, M. S. (2019). Facilitators and Barriers to Implementation of a Peer Support Intervention for Patients with Chronic Pain: A Qualitative Study. Pain Medicine (United States), 20(Issue 7). doi:10.1093/pm/pny229
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  Objective: Pain self-management information and support, delivered by peers, are a potentially useful approach to help patients who are struggling to manage their chronic pain. Before implementation into clinical settings, it is important to understand factors that may influence the success of implementation. The purpose of this study was to explore facilitators and barriers to implementation of peer support for chronic pain. Design: Semistructured interviews were conducted with clinicians who provide care to patients with chronic pain, regarding their perceptions of the proposed peer support intervention. Setting: A single US Veterans Affairs Medical Center. Subjects: Using maximum variation sampling, 15 providers were interviewed (11 women, four men). Clinicians' disciplines included primary care, physical therapy, nursing, clinical psychology, social work, and pharmacy. Results: Findings indicated that clinicians 1) had an overall positive perception of the intervention; 2) had specific intervention outcomes they wanted for patients; 3) anticipated that the intervention could positively influence their role; 4) anticipated barriers to intervention participation and maintenance; and 5) had concerns regarding peer coach selection. Findings are discussed in the context of the Consolidated Framework for Implementation Research. Conclusions: Understanding clinician perceptions of a peer support intervention is critical for successful implementation. The feedback collected in this study will facilitate implementation of the intervention on a broader scale, allowing more patients to benefit.
• Bravata, D. M., Sico, J., Vaz Fragoso, C. A., Miech, E. J., Matthias, M. S., Lampert, R., Williams, L. S., Concato, J., Ivan, C. S., Fleck, J. D., Tobias, L., Austin, C., Ferguson, J., Radulescu, R., Iannone, L., Ofner, S., Taylor, S., Qin, L., Won, C., , Klar Yaggi, H., et al. (2018). Diagnosing and treating sleep apnea in patients with acute cerebrovascular disease. Journal of the American Heart Association, 7(Issue 16). doi:10.1161/jaha.118.008841
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  Background—Obstructive sleep apnea (OSA) is common among patients with acute ischemic stroke and transient ischemic attack. We evaluated whether continuous positive airway pressure for OSA among patients with recent ischemic stroke or transient ischemic attack improved clinical outcomes. Methods and Results—This randomized controlled trial among patients with ischemic stroke/transient ischemic attack compared 2 strategies (standard or enhanced) for the diagnosis and treatment ofOSA versus usual care over 1 year. Primary outcomes were National Institutes of Health Stroke Scale and modified Rankin Scale scores. Among 252 patients (84, control; 86, standard; 82, enhanced), OSA prevalence was as follows: control, 69%; standard, 74%; and enhanced, 80%. Continuous positive airway pressure use occurred on average 50% of nights and was similar among standard (3.9±2.1 mean hours/nights used) and enhanced (4.3±2.4 hours/nights used; P=0.46) patients. In intention-to-treat analyses, changes in National Institutes of Health Stroke Scale and modified Rankin Scale scores were similar across groups. In as-treated analyses among patients with OSA, increasing continuous positive airway pressure use was associated with improved National Institutes of Health Stroke Scale score (no/poor, ˗0.6±2.9; some, ˗0.9±1.4; good, ˗0.3±1.0; P=0.0064) and improved modified Rankin Scale score (no/poor, ˗0.3±1.5; some, ˗0.4±1.0; good, ˗0.9±1.2; P=0.0237). In shift analyses among patients with OSA, 59% of intervention patients had best neurological symptom severity (National Institutes of Health Stroke Scale score, 0-1) versus 38% of controls (P=0.038); absolute risk reduction was 21% (number needed to treat, 4.8). Conclusions—Although changes in neurological functioning and functional status were similar across the groups in the intentionto-treat analyses, continuous positive airway pressure use was associated with improved neurological functioning among patients with acute ischemic stroke/transient ischemic attack with OSA.
• Eliacin, J., Coffing, J. M., Matthias, M. S., Burgess, D. J., Bair, M. J., & Rollins, A. L. (2018). The Relationship Between Race, Patient Activation, and Working Alliance: Implications for Patient Engagement in Mental Health Care. Administration and Policy in Mental Health and Mental Health Services Research, 45(Issue 1). doi:10.1007/s10488-016-0779-5
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  This study explored the relationship between race and two key aspects of patient engagement—patient activation and working alliance—among a sample of African-American and White veterans (N = 152) seeking medication management for mental health conditions. After adjusting for demographics, race was significantly associated with patient activation, working alliance, and medication adherence scores. Patient activation was also associated with working alliance. These results provide support for the consideration of race and ethnicity in facilitating patient engagement and patient activation in mental healthcare. Minority patients may benefit from targeted efforts to improve their active engagement in mental healthcare.
• Kroenke, K., Evans, E., Weitlauf, S., McCalley, S., Porter, B., Williams, T., Baye, F., Lourens, S. G., Matthias, M. S., & Bair, M. J. (2018). Comprehensive vs. Assisted Management of Mood and Pain Symptoms (CAMMPS) trial: Study design and sample characteristics. Contemporary Clinical Trials, 64(Issue). doi:10.1016/j.cct.2017.10.006
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  Background Pain is the most common presenting somatic symptom in medical outpatients, and depression and anxiety are the two most common mental disorders. They frequently co-occur, are under-treated, and result in substantial disability and reduced health-related quality of life. Objectives The Comprehensive vs. Assisted Management of Mood and Pain Symptoms (CAMMPS) study is a randomized comparative effectiveness trial designed to test the relative effectiveness of a lower-resource vs. a higher-resource technology-assisted intervention for the management of patients suffering from pain plus anxiety and/or depression. Methods/design CAMMPS has enrolled 294 primary care patients with chronic pain plus comorbid anxiety and/or depression and randomized them to either: 1) Assisted Symptom Management (ASM) consisting of automated symptom monitoring by interactive voice recording or Internet and prompted pain and mood self-management; or 2) Comprehensive Symptom Management (CSM) which combines ASM with optimized medication management delivered by a nurse-physician specialist team and facilitated mental health care. Outcomes are assessed at baseline, 1, 3, 6, and 12 months. The primary outcome is a composite pain-anxiety-depression (PAD) severity score. Secondary outcomes include individual pain, anxiety, and depression scores, health-related quality of life, disability, healthcare utilization, and treatment satisfaction. Discussion CAMMPS provides an integrated approach to PAD symptoms rather than fragmented care of single symptoms; coordinated symptom management in partnership with primary care clinicians and psychologists embedded in primary care; efficient use of health information technology; attention to physical and psychological symptom comorbidity; and the coupling of self-management with optimized medication management and facilitated mental health care. Trial registration clinicaltrials.gov Identifier: NCT01757301.
• Lee, J. L., Matthias, M. S., Menachemi, N., Frankel, R. M., & Weiner, M. (2018). A critical appraisal of guidelines for electronic communication between patients and clinicians: The need to modernize current recommendations. Journal of the American Medical Informatics Association, 25(Issue 4). doi:10.1093/jamia/ocx089
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  Background: Patient-provider electronic communication has proliferated in recent years, yet there is a dearth of published research either leading to, or including, recommendations that improve clinical care and prevent unintended negative consequences. We critically appraise published guidelines and suggest an agenda for future work in this area. Objective: To understand how existing guidelines align with current practice, evidence, and technology. Methods: We performed a narrative review of provider-targeted guidelines for electronic communication between patients and providers, searching Ovid MEDLINE, Embase, and PubMed databases using relevant terms. We limited the search to articles published in English, and manually searched the citations of relevant articles. For each article, we identified and evaluated the suggested practices. Results: Across 11 identified guidelines, the primary focus was on technical and administrative concerns, rather than on relational communication. Some of the security practices recommended by the guidelines are no longer needed because of shifts in technology. It is unclear the extent to which the recommendations that are still relevant are being followed. Moreover, there is no guideline-cited evidence of the effectiveness of the practices that have been proposed. Conclusion: Our analysis revealed major weaknesses in current guidelines for electronic communication between patients and providers: The guidelines appear to be based on minimal evidence and offer little guidance on how best to use electronic tools to communicate effectively. Further work is needed to systematically evaluate and identify effective practices, create a framework to evaluate quality of communication, and assess the relationship between electronic communication and quality of care.
• Matthias, M. S., Donaldson, M. T., Jensen, A. C., & Krebs, E. E. (2018). “I Was a Little Surprised”: Qualitative Insights From Patients Enrolled in a 12-Month Trial Comparing Opioids With Nonopioid Medications for Chronic Musculoskeletal Pain. Journal of Pain, 19(Issue 9). doi:10.1016/j.jpain.2018.04.008
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  Chronic musculoskeletal pain is a major public health problem. Although opioid prescribing for chronic pain has increased dramatically since the 1990s, this practice has come under scrutiny because of increases in opioid-related harms and lack of evidence for long-term effectiveness. The Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial was a pragmatic 12-month randomized trial comparing the benefits and harms of opioid versus nonopioid medications for chronic musculoskeletal pain. The current qualitative study was designed to better understand trial results by exploring patients’ experiences, including perceptions of medications, experiences with the intervention, and whether expectations were met. Thirty-four participants who were purposefully sampled based on treatment group and intervention response participated in semistructured interviews. The constant comparison method guided analysis. Results revealed that participants often held strong beliefs about opioid medications, which sometimes changed during the trial as they gained experience with medications; participants described a wide variety of experiences with treatment effectiveness, regardless of study group or their response to the intervention; and participants highly valued the personalized pain care model used in SPACE. Perspective: SPACE trial results indicated no advantage for opioid over nonopioid medications. Qualitative findings suggest that, for both treatment groups, preexisting expectations and anticipated improvement in pain shaped experiences with and responses to medications. The personalized pain care model was described as contributing to positive outcomes in both groups.
• Mosher, C. E., Daily, S., Tometich, D., Matthias, M. S., Outcalt, S. D., Hirsh, A., Johns, S. A., Rand, K., Schneider, B., Mina, L., Storniolo, A. M., Newton, E., & Miller, K. (2018). Factors underlying metastatic breast cancer patients' perceptions of symptom importance: a qualitative analysis. European Journal of Cancer Care, 27(Issue 1). doi:10.1111/ecc.12540
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  The symptom literature in cancer has primarily examined symptom severity, frequency and distress. Assessing cancer patients' perceptions of symptom importance—how important it is for them to see improvement in a symptom following an intervention—and factors influencing these judgments would also inform patient-centred care, but this analysis has not been undertaken. This qualitative study aimed to identify factors underlying perceptions of symptom importance among 25 symptomatic metastatic breast cancer (MBC) patients. Participants were recruited from a cancer centre in the Midwestern USA. Semi-structured interviews focused on patients' rationale for considering common symptoms (i.e., anxiety, sadness, sleep problems, pain or fatigue) to be important. Thematic analyses revealed five interrelated factors underlying MBC patients' perceptions of symptom importance: activity restriction, concentration difficulties, exacerbation of other physical symptoms, symptom-related long-term health concerns and negative impact on their relationships with others. Patients most frequently stated that a physical or psychological symptom was important because of the resulting activity restriction. Additionally, some patients considered pain to be important because it signalled potential long-term health concerns, such as worsening metastatic disease. Findings suggest that clinicians should take into account MBC patients' perceptions of symptom importance and factors underlying these judgments when making shared treatment decisions.
• Tometich, D. B., Mosher, C. E., Hirsh, A. T., Rand, K. L., Johns, S. A., Matthias, M. S., Outcalt, S. D., Schneider, B. P., Mina, L., Storniolo, A. M., Newton, E. V., & Miller, K. D. (2018). Metastatic breast cancer patients’ expectations and priorities for symptom improvement. Supportive Care in Cancer, 26(Issue 11). doi:10.1007/s00520-018-4244-8
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  Purpose: Little research has examined cancer patients’ expectations, goals, and priorities for symptom improvement. Thus, we examined these outcomes in metastatic breast cancer patients to provide patients’ perspectives on clinically meaningful symptom improvement and priorities for symptom management. Methods: Eighty women with metastatic breast cancer participated in a survey with measures of comorbidity, functional status, engagement in roles and activities, distress, quality of life, and the modified Patient-Centered Outcomes Questionnaire that focused on 10 common symptoms in cancer patients. Results: On average, patients reported low to moderate severity across the 10 symptoms and expected symptom treatment to be successful. Patients indicated that a 49% reduction in fatigue, 48% reduction in thinking problems, and 43% reduction in sleep problems would represent successful symptom treatment. Cluster analysis based on ratings of the importance of symptom improvement yielded three clusters of patients: (1) those who rated thinking problems, sleep problems, and fatigue as highly important, (2) those who rated pain as moderately important, and (3) those who rated all symptoms as highly important. The first patient cluster differed from other subgroups in severity of thinking problems and education. Conclusions: Metastatic breast cancer patients report differing symptom treatment priorities and criteria for treatment success across symptoms. Considering cancer patients’ perspectives on clinically meaningful symptom improvement and priorities for symptom management will ensure that treatment is consistent with their values and goals.
• Bravata, D. M., McClain, V., Austin, C., Ferguson, J., Burrus, N., Miech, E. J., Matthias, M. S., Chumbler, N., Ofner, S., Foresman, B., Sico, J., Vaz Fragoso, C. A., Williams, L. S., Agarwal, R., Concato, J., & Klar Yaggi, H. (2017). Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease: a randomized trial of a home-based strategy. Sleep and Breathing, 21(Issue 3). doi:10.1007/s11325-017-1494-5
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  Background: Obstructive sleep apnea is common and associated with poor outcomes after stroke or transient ischemic attack (TIA). We sought to determine whether the intervention strategy improved sleep apnea detection, obstructive sleep apnea (OSA) treatment, and hypertension control among patients with chronic cerebrovascular disease and hypertension. Methods: In this randomized controlled strategy trial intervention, patients received unattended polysomnography at baseline, and patients with OSA (apnea-hypopnea index ≥5 events/h) received auto-titrating continuous positive airway pressure (CPAP) for up to 1 year. Control patients received usual care and unattended polysomnography at the end of the study, to identify undiagnosed OSA. Both groups received 24-h blood pressure assessments at baseline and end of the study. “Excellent” CPAP adherence was defined as cumulative use of ≥4 h/night for ≥70% of the nights. Results: Among 225 randomized patients (115 control; 110 intervention), 61.9% (120/194) had sleep apnea. The strategy successfully diagnosed sleep apnea with 97.1% (102/105) valid studies; 90.6% (48/53, 95% CI 82.7–98.4%) of sleep apnea was undiagnosed among control patients. The intervention improved long-term excellent CPAP use: 38.6% (22/57) intervention versus 0% (0/2) control (p < 0.0001). The intervention did not improve hypertension control in this population with well-controlled baseline blood pressure: intervention, 132.7 mmHg (±standard deviation, 14.1) versus control, 133.8 mmHg (±14.0) (adjusted difference, −1.1 mmHg, 95% CI (−4.2, 2.0)), p = 0.48). Conclusions: Patients with cerebrovascular disease and hypertension have a high prevalence of OSA. The use of portable polysomnography, and auto-titrating CPAP in the patients’ homes, improved both the diagnosis and the treatment for sleep apnea compared with usual care but did not lower blood pressure.
• Matthias, M. S., Fukui, S., & Salyers, M. P. (2017). What Factors are Associated with Consumer Initiation of Shared Decision Making in Mental Health Visits?. Administration and Policy in Mental Health and Mental Health Services Research, 44(Issue 1). doi:10.1007/s10488-015-0688-z
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  Understanding consumer initiation of shared decision making (SDM) is critical to improving SDM in mental health consultations, particularly because providers do not always invite consumer participation in treatment decisions. This study examined the association between consumer initiation of nine elements of SDM as measured by the SDM scale, and measures of consumer illness self-management and the consumer–provider relationship. In 63 mental health visits, three SDM elements were associated with self-management or relationship factors: discussion of consumer goals, treatment alternatives, and pros and cons of a decision. Limitations, implications, and future directions are discussed.
• Matthias, M. S., Johnson, N. L., Shields, C. G., Bair, M. J., MacKie, P., Huffman, M., & Alexander, S. C. (2017). “I'm Not Gonna Pull the Rug out From Under You”: Patient-Provider Communication About Opioid Tapering. Journal of Pain, 18(Issue 11). doi:10.1016/j.jpain.2017.06.008
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  In response to increases in harms associated with prescription opioids, opioid prescribing has come under greater scrutiny, leading many health care organizations and providers to consider or mandate opioid dose reductions (tapering) for patients with chronic pain. Communicating about tapering can be difficult, particularly for patients receiving long-term opioids who perceive benefits and are using their medications as prescribed. Because of the importance of effective patient–provider communication for pain management and recent health system-level initiatives and provider practices to taper opioids, this study used qualitative methods to understand communication processes related to opioid tapering, to identify best practices and opportunities for improvement. Up to 3 clinic visits per patient were audio-recorded, and individual interviews were conducted with patients and their providers. Four major themes emerged: 1) explaining—patients needed to understand individualized reasons for tapering, beyond general, population-level concerns such as addiction potential, 2) negotiating—patients needed to have input, even if it was simply the rate of tapering, 3) managing difficult conversations—when patients and providers did not reach a shared understanding, difficulties and misunderstandings arose, and 4) nonabandonment—patients needed to know that their providers would not abandon them throughout the tapering process. Perspective Although opioid tapering can be challenging, helping patients to understand individualized reasons for tapering, encouraging patients to have input into the process, and assuring patients they would not be abandoned all appear to facilitate optimal communication about tapering.
• Mosher, C. E., Tometich, D. B., Hirsh, A., Rand, K. L., Johns, S. A., Matthias, M. S., Outcalt, S. D., Bricker, J., Schneider, B., Mina, L., Storniolo, A. M., Newton, E., & Miller, K. (2017). Symptom experiences in metastatic breast cancer patients: relationships to activity engagement, value-based living, and psychological inflexibility. Psycho-Oncology, 26(Issue 11). doi:10.1002/pon.4283
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  Objective: This study examined symptom-based subgroups of metastatic breast cancer (MBC) patients and the extent to which they differed across key constructs of acceptance and commitment therapy (ACT). Methods: Eighty women with MBC completed self-report surveys assessing 10 common symptoms and several ACT variables (ie, activity engagement, psychological inflexibility, value obstruction, and value progress) during a single time point. Results: A cluster analysis yielded 3 patient subgroups: low symptoms, low-moderate symptoms, and moderate-high symptoms. Relative to the subgroup with low symptoms, the other subgroups reported less activity engagement. In addition, compared with patients with low symptoms, the subgroup with moderate-high symptoms reported greater psychological inflexibility (ie, avoidance of unwanted internal experiences) and greater difficulty living consistently with their values. Conclusions: Women with MBC show heterogeneity in their symptom profiles, and those with higher symptom burden are more likely to disengage from valued activities and avoid unwanted experiences (eg, thoughts, feelings, and bodily sensations). Findings are largely consistent with the ACT model and provide strong justification for testing ACT to address symptom interference in MBC patients.
• Outcalt, S. D., Nicolaidis, C., Bair, M. J., Myers, L. J., Miech, E. J., & Matthias, M. S. (2017). A qualitative examination of pain centrality among veterans of Iraq and Afghanistan conflicts. Pain Medicine (United States), 18(Issue 2). doi:10.1093/pm/pnw137
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  Objective. Centrality of pain refers to the degree to which a patient views chronic pain as integral to his or her life or identity. The purpose of this study was to gain a richer understanding of pain centrality from the perspective of patients who live with chronic pain. Methods. Face-to-face interviews were conducted with 26 Veterans with chronic and disabling musculoskeletal pain after completing a stepped care intervention within a randomized controlled trial. Qualitative data were analyzed using an immersion/ crystallization approach. We evaluated the role centrality plays in Veterans' lives and examined whether and how their narratives differ when centrality either significantly decreases or increases after participation in a stepped care intervention for chronic pain. Results. Our data identified three emergent themes that characterized pain centrality: 1) control, 2) acceptance, and 3) preoccupation. We identified five characteristics that distinguished patients' changes in centrality from baseline: 1) biopsychosocial viewpoint, 2) activity level, 3) pain communication, 4) participation in managing own pain, and 5) social support. Conclusions. This study highlights centrality of pain as an important construct to consider within the overall patient experience of chronic pain.
• Rattray, N. A., Sico, J. J., Cox, L. A., Russ, A. L., Matthias, M. S., & Frankel, R. M. (2017). Crossing the communication chasm: Challenges and opportunities in transitions of care from the hospital to the primary care clinic. Joint Commission Journal on Quality and Patient Safety, 43(Issue 3). doi:10.1016/j.jcjq.2016.11.007
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  Background: Transitions of care from specialty and acute settings to primary care abound. Compared to the continuity in end-of-shift handoffs, care transitions involve provider communication between practices and facilities with their own cultures and bureaucracies. Using the transition from acute care to outpatient primary care for stroke/transient ischemic attack (TIA) patients as a case study, this qualitative research explored communication practices and institutional arrangements among clinical providers responsible for longitudinal management of hypertension. In this study, researchers investigated the barriers and facilitators of effective communication between acute stroke/TIA inpatient and primary care providers at a Veterans Affairs Medical Center. Methods: A multidisciplinary team conducted consensus-based coding and thematic analysis of semistructured interviews with 21 clinical providers (9 with primary responsibilities for inpatient care and 12 with primary responsibilities in outpatient, primary care). Results: Thematic analysis of responses identified three factors that influenced communication between clinical providers: (1) consistent, concise but complete medication and treatment plans; (2) reliable, standardized discharge documentation; (3) use of multiple modes of communication. Participants identified cultural barriers, including challenges with rotating providers at a teaching hospital and local discharge practices. Conclusion: Ambiguity about who is being handed off to and time pressures in the acute setting may lead inpatient providers to give lower priority to discharge communication, leaving outpatient providers with low-quality information. While electronic templates have standardized key components of discharge documentation, improvement opportunities remain. Increased awareness of the challenges and opportunities on each side of the care transfer could foster communication practices that systematically account for the information needs of inpatient and outpatient providers.
• Tucker Edmonds, B., McKenzie, F., Austgen, M. B., Ashburn-Nardo, L., Matthias, M. S., & Hirsh, A. T. (2017). Obstetrical Providers' Management of Chronic Pain in Pregnancy: A Vignette Study. Pain medicine (Malden, Mass.), 18(Issue 5). doi:10.1093/pm/pnw195
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  Objective: Describe obstetrical providers' management of a hypothetical case on chronic pain in pregnancy and determine whether practices differ based on patient race. Design and Setting: This was a self-administered survey at a clinical conference. Subjects: Seventy-six obstetrician-gynecologists and one nurse practitioner were surveyed. Methods: A case-vignette described a pregnant patient presenting with worsening chronic lower back pain, requesting an opioid refill and increased dosage. We varied patient race (black/white) across two randomly assigned identical vignettes. Providers indicated their likelihood of prescribing opioids, drug testing, and referring on a 0 (definitely would not) to 10 (definitely would) scale; rated their suspicions/concerns about the patient on a 0-10 VAS scale; and ranked those concerns in order of importance. We calculated correlation coefficients, stratifying analyses by patient race. Results: Providers were not inclined to refill the opioid prescription (median = 3.0) or increase the dose (median = 1.0). They were more likely to conduct urine drug tests on white than black patients ( P = 0.008) and more likely to suspect that white patients would divert the medication ( P =0.021). For white patients, providers' highest-ranked concern was the patient's risk of abuse/addiction, whereas, for black patients, it was harm to the fetus. Suspicion about symptom exaggeration was more closely related to decisions about refilling the opioid prescriptions and increasing the dose for black patients (r = -0.357, -0.439, respectively), whereas these decisions were more closely correlated with concerns about overdose for white patients (r = -0.406, -0.494, respectively). Conclusions: Provider suspicion and concerns may differ by patient race, which may relate to differences in pain treatment and testing. Further study is warranted to better understand how chronic pain is managed in pregnancy.
• Bauer, S. M., McGuire, A. B., Kukla, M., McGuire, S., Bair, M. J., & Matthias, M. S. (2016). Veterans’ pain management goals: Changes during the course of a peer-led pain self-management program. Patient Education and Counseling, 99(Issue 12). doi:10.1016/j.pec.2016.07.034
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  Objective Goal setting is a common element of self-management support programs; however, little is known about the nature of patients’ goals or how goals change during pain self-management. The purpose of the current study is to explore how patients’ goals and views of goal setting change over the course of a peer-led pain self-management program. Methods Veterans (n = 16) completing a 4-month peer-led pain self-management program completed semi-structured interviews at baseline and follow-up regarding their goals for their pain. Interviews were analyzed using immersion/crystallization. Results Analyses revealed six themes: motivation to do something for their pain, more goal-oriented, actually setting goals, clarity of goal importance, more specific/measurable goal criteria, and more specific/measurable strategies. Conclusion The current analyses illustrate how participants’ goals can evolve over the course of a peer-led pain self-management program. Specifically, increased motivation, more openness to using goals, greater clarity of goal importance, more specific and measurable goals and strategies, and the influence of the peer coach relationship were described by participants. Practice implications Pain self-management interventions should emphasize goal setting, and development of specific, measurable goals and plans. Trainings for providers should address the potential for the provider-patient relationship, particularly peer providers, to facilitate motivation and goal setting.
• Eliacin, J., Rollins, A. L., Burgess, D. J., Salyers, M. P., & Matthias, M. S. (2016). Engaging african-American veterans in mental health care patients' perspectives. Journal of Nervous and Mental Disease, 204(Issue 4). doi:10.1097/nmd.0000000000000479
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  Despite growing interest in patient engagement, the concept remains poorly defined. Moreover, patients' perspectives on engagement are lacking, particularly those of minority patients. A better understanding of patients' views and what influences their engagement in health services will facilitate better patient education and implementation practices to enhance patient participation in health care. This article addresses patients' perspectives of facilitators and barriers to engagement in outpatient mental health services. Forty-nine African-American veterans with mental illness receiving routine medication management visits were interviewed. Qualitative data analysis was guided by a constructivist grounded theory approach. Participants identified several barriers and facilitators to engagement in mental health services, including patient as well as providerrelated factors. Results emphasize the role of providers in facilitating sustained involvementof patients in their own care. Based on the findings, the authors offer a preliminary framework for patient engagement that encompasses patient and provider factors.
• Eliacin, J., Rollins, A. L., Burgess, D. J., Salyers, M. P., & Matthias, M. S. (2016). Patient activation and visit preparation in African American veterans receiving mental health care. Cultural Diversity and Ethnic Minority Psychology, 22(Issue 4). doi:10.1037/cdp0000086
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  Objective: Patient activation refers to one's ability and willingness to manage their health and health care. Visit preparation, question formulation, and other elements of patient activation are core components of patient-centered care. However, they are inconsistently translated into clinical practice. Multiple factors have been shown to influence patient activation and associated activities, such as patients' race and ethnicity, illness, and clinical settings. Because race and ethnicity are important factors in patient activation, and we know little about ethnic minority patients with respect to patient activation, the goal of this study was to examine the contexts, barriers, and facilitators influencing African American veterans' involvement in visit preparation in mental health outpatient settings. Method: We conducted qualitative interviews with 49 African American veterans with mental illness receiving outpatient psychiatric care at a large, urban U.S. Department of Veterans Affairs (VA) Medical Center, and used a grounded theory approach to analyze the data. Results: Findings from this study identify patients' beliefs about preparing for the clinical encounter, the patient-provider relationship, and lack of information about patient activation as barriers to engaging in visit preparation activities. Conclusions and Implications for Practice: Findings indicate the need for greater awareness of the challenges of visit preparation as well as the potential consequences of lack of preparation. Results suggest the incorporation of visit preparation as part of routine mental health visits, and as a tool to increase patient activation, especially among minorities. Findings also inform intervention studies by emphasizing the need to explore sociocultural factors that may impact patient activation programs.
• Henry, S. G., Chen, M., Matthias, M. S., Bell, R. A., & Kravitz, R. L. (2016). Development of the chronic pain coding system (CPCS) for characterizing patient-clinician discussions about chronic pain and opioids. Pain Medicine (United States), 17(Issue 10). doi:10.1093/pm/pnw005
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  Objective. To describe the development and initial application of the Chronic Pain Coding System. Design. Secondary analysis of data from a randomized clinical trial. Setting. Six primary care clinics in northern California. Subjects. Forty-five primary care visits involving 33 clinicians and 45 patients on opioids for chronic noncancer pain. Methods. The authors developed a structured coding system to accurately and objectively characterize discussions about pain and opioids. Two coders applied the final system to visit transcripts. Intercoder agreement for major coding categories was moderate to substantial (kappa = 0.5-0.7). Mixed effects regression was used to test six hypotheses to assess preliminary construct validity. Results. Greater baseline pain interference was associated with longer pain discussions (P = 0.007) and more patient requests for clinician action (P = 0.02) but not more frequent negative patient evaluations of pain (P = 0.15). Greater clinician-reported visit difficulty was associated with more frequent disagreements with clinician recommendations (P = 0.003) and longer discussions of opioid risks (P = 0.049) but not more frequent requests for clinician action (P = 0.11). Rates of agreement versus disagreement with patient requests and clinician recommendations were similar for opioid-related and non-opioid-related utterances. Conclusions. This coding system appears to be a reliable and valid tool for characterizing patient-clinician communication about opioids and chronic pain during clinic visits. Objective data on how patients and clinicians discuss chronic pain and opioids are necessary to identify communication patterns and strategies for improving the quality and productivity of discussions about chronic pain that may lead to more effective pain management and reduce inappropriate opioid prescribing.
• Koo, B. B., Bravata, D. M., Tobias, L. A., Mackey, J. S., Miech, E. J., Matthias, M. S., Stahl, S. M., Sico, J. J., Vaz Fragoso, C. A., Williams, L. S., Lampert, R., Qin, L., & Yaggi, H. K. (2016). Observational study of obstructive sleep apnea in wake-up stroke: The SLEEP TIGHT study. Cerebrovascular Diseases, 41(Issue 5-6). doi:10.1159/000440736
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  Background: Wake-up stroke (WUS) accounts for a quarter of all ischemic strokes. Its conspicuous occurrence during sleep suggests that WUS may be associated with obstructive sleep apnea (OSA). We investigated the potential association among WUS, OSA, and measures of sympathetic hyperactivity. Methods: This is a cross-sectional analysis of data from the Sleep Apnea in Transient Ischemic Attack and Stroke (SLEEP TIGHT) study. Ischemic stroke patients were divided into WUS and non-WUS groups. Participants underwent polysomnography and ambulatory blood pressure monitoring. Collected data included demographic, medical, stroke characteristics (including severity by National Institutes of Health Stroke Scale), cholesterol, serum catecholamines, C-reactive protein, interleukin-6, B-type natriuretic peptide, blood pressure, and polysomnographic (apnea-hypopnea index (AHI); measures of hypoxia). Because both stroke and OSA affect men and women to varying degrees, the cohort was considered as a whole and by gender stratification. Results: Among 164 participants, 30.3% had WUS. The mean age was 62.0 ± 11.3 and the mean body mass index was 30.2 ± 7.9 kg/m2. One-hundred-and-five participants (63.6%) were males and 92 participants (56.8%) were Caucasian. Neither AHI nor OSA (AHI ≥5) frequency differed between WUS and non-WUS groups. Men tended to be more likely than women to have WUS (74.0 vs. 59.6%; p = 0.08), but this was not statistically significant. In gender-stratified analyses, men with WUS compared to men with non-WUS had significantly higher rates of severe OSA (AHI >30: 45.0 vs. 17.6%; p = 0.03) and tended toward more 3% oxygen desaturation events (57.0 ± 63.9 vs. 31.8 ± 22.9; p = 0.06). These differences were not seen in women. WUS patients tended to be of the male gender (74.0 vs. 59.6%; p = 0.08). History of stroke, hypertension, diabetes, dyslipidemia, or atrial fibrillation, serum catecholamines, and inflammatory biomarkers was no different between the groups. Low-density lipoprotein (LDL) was significantly higher in WUS (114.5 ± 36.3 vs. 101.4 ± 37.6; p = 0.04). Baseline diastolic blood pressure (DBP) was significantly greater in the WUS group. There was no difference in systolic or ambulatory blood pressure (including nighttime blood pressure) between WUS and non-WUS groups. Conclusions: WUS may be associated with severe OSA with more oxygen desaturation in men but not in women. WUS may be associated with high DBP and increased LDL cholesterol.
• Livorsi, D., Comer, A. R., Matthias, M. S., Perencevich, E. N., & Bair, M. J. (2016). Barriers to guideline-concordant antibiotic use among inpatient physicians: A case vignette qualitative study. Journal of Hospital Medicine, 11(Issue 3). doi:10.1002/jhm.2495
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  BACKGROUND: Greater adherence to antibiotic-prescribing guidelines may promote more judicious antibiotic use, which could benefit individual patients and society at large. OBJECTIVE: To assess physician knowledge and acceptance of antibiotic-prescribing guidelines through the use of case vignettes. DESIGN: We conducted semistructured interviews with 30 inpatient physicians. Participants were asked to respond to 3 hypothetical case vignettes: (1) a skin and soft tissue infection (SSTI), (2) suspected hospital-acquired pneumonia (HAP), and (3) asymptomatic bacteriuria (ASB). All participants received feedback according to guidelines from the Infectious Diseases Society of America (IDSA) and were asked to discuss their level of comfort with following these guidelines. SETTING: Two acute care teaching hospitals for adult patients. INTERVENTION: None. MEASUREMENTS: Data from transcribed interviews were analyzed using emergent thematic analysis. RESULTS: Participants were receptive to guidelines and believed they were useful. However, participants' responses to the case vignettes demonstrated that IDSA guideline recommendations were not routinely followed for SSTI, HAP, and ASB. We identified 3 barriers to guideline-concordant care: (1) physicians' lack of awareness of specific guideline recommendations; (2) tension between adhering to guidelines and the desire to individualize patient care; and (3) skepticism of certain guideline recommendations. CONCLUSIONS: Case vignettes may be useful tools to assess physician knowledge and acceptance of antibiotic-prescribing guidelines. Using case vignettes, we identified 3 barriers to following IDSA guidelines. Efforts to improve guideline-concordant antibiotic prescribing should focus on reducing such barriers at the local level.
• Matthias, M. S., Kukla, M., McGuire, A. B., & Bair, M. J. (2016). How do patients with chronic pain benefit from a peer-supported pain self-management intervention? A qualitative investigation. Pain Medicine (United States), 17(Issue 12). doi:10.1093/pm/pnw138
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  Objective. Peer support is a novel and understudied approach to the management of chronic pain. This study's purpose was to uncover the elements of a peer-supported self-management intervention that are perceived by participants as essential to achieving positive changes. Design. Qualitative, semi-structured interviews. Methods. Veterans and veteran peer coaches who participated in a pilot study of peer support Improving Pain using Peer-Reinforced Self- Management Strategies (IMPPRESS, NCT01748227) took part in qualitative semi-structured interviews after completing the 4-month intervention. Questions were designed to facilitate understanding of how participants experienced the intervention. An immersion/crystallization approach was used to analyze data. Results. All 26 peer coaches and patients who completed the intervention were interviewed. Qualitative analysis revealed three elements of IMPPRESS that peer coaches and patients believed conferred benefit: 1) making interpersonal connections; 2) providing/receiving encouragement and support; and 3) facilitating the use of pain selfmanagement strategies. Conclusions. Peer support represents a promising approach to chronic pain management that merits further study. The current study helps to identify intervention elements perceived by participants to be important in achieving positive results. Understanding how peer support may benefit patients is essential to optimize the effectiveness of peer support interventions and increase the implementation potential of peer-supported pain selfmanagement into clinical practice.
• Matthias, M. S., Kukla, M., McGuire, A. B., Damush, T. M., Gill, N., & Bair, M. J. (2016). Facilitators and barriers to participation in a peer support intervention for veterans with chronic pain. Clinical Journal of Pain, 32(Issue 6). doi:10.1097/ajp.0000000000000297
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  Objective: To understand facilitators and barriers to participation in a peer support intervention for self-management of chronic pain. Methods: After completing a pilot intervention study, peer coaches and their veteran patients took part in a qualitative, semistructured interview to explore their experiences with the intervention. Data were analyzed using an immersion/crystallization approach. Results: Three facilitators and 2 barriers to patient participation in a peer support intervention for veterans with chronic pain emerged. Facilitators were (1) having a shared identity as veterans, (2) being partnered with a person who also has chronic pain, and (3) support from the study staff. Barriers were (1) logistical challenges, and (2) challenges to motivation and engagement in the intervention. Discussion: Awareness of facilitators and barriers to participation in a peer-supported self-management program for chronic pain, as well as strategies to capitalize on facilitators and mitigate barriers, are essential for further study and ultimate clinical implementation of such a program.
• Ross, J. S., Williams, L., Damush, T. M., & Matthias, M. (2016). Physician and other healthcare personnel responses to hospital stroke quality of care performance feedback: A qualitative study. BMJ Quality and Safety, 25(Issue 6). doi:10.1136/bmjqs-2015-004197
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  Background Understanding how physicians and other healthcare personnel respond to hospital performance feedback initiatives may have important implications for quality improvement efforts. Our objective was to explore responses to the inaugural feedback of hospital performance on stroke quality of care measures among relevant physicians and personnel at the US Department of Veterans Health Administration (VHA) hospitals. Methods Qualitative interviews with hospital administrators, physicians, nurses and quality managers at 12 VHA hospitals in the USA after the inaugural national release of the report on quality of acute stroke care processes. Interview transcripts were analysed using an immersion/ crystallisation approach to identify recurrent themes. Results Interviews were completed with 41 individuals at 12 VHA hospitals from diverse regions of the USA; the majority were clinicians, either physicians or nurses, and nearly all had 20 years of experience or more. Interviewees described general perceptions of internal performance feedback that were both positive and negative, such as the notion that performance feedback could provide value to clinicians and hospitals, but at the same time voiced concerns about being inundated with such data. Interviewees also expressed scepticism about public reporting of performance data, citing numerous concerns and limitations. However, when interviewees described specific experiences with performance feedback, nearly all reactions were positive, including excitement, interest and feeling validated about a job well done. Discussion Physicians and other healthcare personnel described hospital performance feedback on stroke quality of care measures to be broadly valuable but identified areas of concern related to the measurement process and public reporting.
• Bidassie, B., Williams, L. S., Woodward-Hagg, H., Matthias, M. S., & Damush, T. M. (2015). Key components of external facilitation in an acute stroke quality improvement collaborative in the Veterans Health Administration. Implementation Science, 10(Issue 1). doi:10.1186/s13012-015-0252-y
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  Background: Facilitation is a key component for successful implementation in several implementation frameworks; however, there is a paucity of research specifying this component. As part of a stroke quality improvement intervention in the Veterans Health Administration (VHA), facilitation plus data feedback was compared to data feedback alone in 11 VA medical facilities. The objective of this study was to elucidate upon the facilitation components of the stroke quality improvement. Methods: We conducted a secondary evaluation of external facilitation using semi-structured interviews. Five facilitators and two program directors were interviewed. Qualitative analysis was performed on transcribed interviews to gain an understanding of the role and activities of external facilitators during the on-site and telephone facilitation. Quantitative frequencies were calculated from the self-reported time spent in facilitation tasks by facilitators. Results: The external facilitators saw their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. To fulfill this role, they reported engaging in a number of core tasks during telephone and on-site visits including: assessing the context in which the teams were currently operating, guiding the clinical teams through their planned changes and use of process improvement tools, identifying resources and making referrals, holding teams accountable for plan implementation with on-site visits, and providing support and encouragement to the teams. Time spent in facilitation activities changed across time from guiding change (early) to supporting efforts made by the clinical teams (later). Facilitation activity transitioned to more monitoring, problem solving, and intentional work to hand over the clinical improvement process to the site teams with the coach's role being increasingly that of a more distant consultant. Overall, this study demonstrated that external facilitation is not an event but rather a process where relationships and responsibilities evolve over time. Conclusions: This study shows that external facilitation involves core elements related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving. Importantly, this work demonstrates the fluid nature of external facilitation over time, as teams learn, grow, change, and experience changing contexts.
• Eliacin, J., Salyers, M. P., Kukla, M., & Matthias, M. S. (2015). Factors influencing patients' preferences and perceived involvement in shared decision-making in mental health care. Journal of Mental Health, 24(Issue 1). doi:10.3109/09638237.2014.954695
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  Background: Although research has suggested that patients desire to participate in shared decision-making, recent studies show that most patients take a passive role in their treatment decisions. The discrepancy between patients' expressed desire and actual behaviors underscores the need to better understand how patients perceive shared decision-making and what factors influence their participation. Aims: To investigate patients' preferences and appraisals of their involvement in treatment decisions. Methods: Fifty-four qualitative interviews were conducted with veterans receiving outpatient mental health care at a U.S. Veterans Affairs Medical Center. Interviews were analyzed using thematic analysis. Results: Participants outlined several factors that influence their preferences and involvement in treatment decisions. These include the patient-provider relationship, fear of being judged, perceived inadequacy, and a history of substance abuse. Conclusion: Patients' preferences and willingness to engage in shared decision-making fluctuate over time and are context dependent. A better understanding of these factors and a strong patient-provider relationship will facilitate better measurement and implementation of shared decision-making.
• Eliacin, J., Salyers, M. P., Kukla, M., & Matthias, M. S. (2015). Patients' understanding of shared decision making in a mental health setting. Qualitative Health Research, 25(Issue 5). doi:10.1177/1049732314551060
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  Shared decision making is a fundamental component of patient-centered care and has been linked to positive health outcomes. Increasingly, researchers are turning their attention to shared decision making in mental health; however, few studies have explored decision making in these settings from patients' perspectives. We examined patients' accounts and understanding of shared decision making. We analyzed interviews from 54 veterans receiving outpatient mental health care at a Department of Veterans Affairs Medical Center in the United States. Although patients' understanding of shared decision making was consistent with accounts published in the literature, participants reported that shared decision making goes well beyond these components. They identified the patient-provider relationship as the bedrock of shared decision making and highlighted several factors that interfere with shared decision making. Our findings highlight the importance of the patient-provider relationship as a fundamental element of shared decision making and point to areas for potential improvement.
• Fukui, S., Matthias, M. S., & Salyers, M. P. (2015). Core Domains of Shared Decision-Making During Psychiatric Visits: Scientific and Preference-Based Discussions. Administration and Policy in Mental Health and Mental Health Services Research, 42(Issue 1). doi:10.1007/s10488-014-0539-3
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  Shared decision-making (SDM) is imperative to person-centered care, yet little is known about what aspects of SDM are targeted during psychiatric visits. This secondary data analysis (191 psychiatric visits with 11 providers, coded with a validated SDM coding system) revealed two factors (scientific and preference-based discussions) underlying SDM communication. Preference-based discussion occurred less. Both provider and consumer initiation of SDM elements and decision complexity were associated with greater discussions in both factors, but were more strongly associated with scientific discussion. Longer visit length correlated with only scientific discussion. Providers’ understanding of core domains could facilitate engaging consumers in SDM.
• Hollingshead, N. A., Matthias, M. S., Bair, M. J., & Hirsh, A. T. (2015). Impact of Race and Sex on Pain Management by Medical Trainees: A Mixed Methods Pilot Study of Decision Making and Awareness of Influence. Pain Medicine (United States), 16(Issue 2). doi:10.1111/pme.12506
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  Objective: Previous research suggests female and black patients receive less optimal treatment for their chronic pain compared with male and white patients. Provider-related factors are hypothesized to contribute to unequal treatment, but these factors have not been examined extensively. This mixed methods investigation examined the influence of patients' demographic characteristics on providers' treatment decisions and providers' awareness of these influences on their treatment decisions. Methods: Twenty medical trainees made treatment decisions (opioid, antidepressant, physical therapy) for 16 virtual patients with chronic low back pain; patient sex and race were manipulated across patients. Participants then indicated from a provided list the factors that influenced their treatment decisions, including patient demographics. Finally, individual interviews were conducted to discuss the role of patient demographics on providers' clinical decisions. Results: Individual regression analyses indicated that 30% of participants were reliably influenced by patient sex and 15% by patient race when making their decisions (P
• Livorsi, D., Comer, A., Matthias, M. S., Perencevich, E. N., & Bair, M. J. (2015). Factors influencing antibiotic-prescribing decisions among inpatient physicians: A qualitative investigation. Infection Control and Hospital Epidemiology, 36(Issue 9). doi:10.1017/ice.2015.136
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  objective. To understand the professional and psychosocial factors that influence physician antibiotic prescribing habits in the inpatient setting. design. We conducted semi-structured interviews with 30 inpatient physicians. Interviews consisted of open-ended questions and flexible probes based on participant responses. Interviews were audio recorded, transcribed, de-identified, and reviewed for accuracy and completeness. Data were analyzed using emergent thematic analysis. setting. Two teaching hospitals in Indianapolis, Indiana participants. A total of 30 inpatient physicians (10 physicians-in-training, 20 supervising staff) were enrolled in this study. results. Participants recognized that antibiotics are overused, and many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain. Overprescription was largely driven by anxiety about missing an infection, whereas potential adverse effects of antibiotics did not strongly influence decision making. Participants did not routinely disclose potential adverse effects of antibiotics to inpatients. Physicians-in-training were strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians. Participants sometimes questioned their colleagues’ antibiotic prescribing decisions, but they frequently avoided providing direct feedback or critique. These physicians cited obstacles of hierarchy, infrequent face-to-face encounters, and the awkwardness of these conversations. conclusion. A physician-based culture of prescribing antibiotics involves overusing antibiotics and not challenging the decisions of colleagues. The potential adverse effects of antibiotics did not strongly influence decision making in this sample. A better understanding of these factors could be leveraged in future efforts to improve antibiotic prescribing practices in the inpatient setting.
• Matthias, M. S., Mcguire, A. B., Kukla, M., Daggy, J., Myers, L. J., & Bair, M. J. (2015). A brief peer support intervention for veterans with chronic musculoskeletal pain: A pilot study of feasibility and effectiveness. Pain Medicine (United States), 16(Issue 1). doi:10.1111/pme.12571
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  Objective: The aim of this study was to pilot test a peer support intervention, involving peer delivery of pain self-management strategies, for veterans with chronic musculoskeletal pain. Design: Pretest/posttest with 4-month intervention period. Methods: Ten peer coaches were each assigned 2 patients (N=20 patients). All had chronic musculoskeletal pain. Guided by a study manual, peer coach-patient pairs were instructed to talk biweekly for 4 months. Pain was the primary outcome and was assessed with the PEG, a three-item version of the Brief Pain Inventory, and the PROMIS Pain Interference Questionnaire. Several secondary outcomes were also assessed. To assess change in outcomes, a linear mixed model with a random effect for peer coaches was applied. Results: Nine peer coaches and 17 patients completed the study. All were male veterans. Patients' pain improved at 4 months compared with baseline but did not reach statistical significance (PEG: P=0.33, ICC [intra-class correlation]=0.28, Cohen's d=-0.25; PROMIS: P=0.17, d=-0.35). Of secondary outcomes, self-efficacy (P=0.16, ICC=0.56, d=0.60) and pain centrality (P=0.06, ICC=0.32, d=-0.62) showed greatest improvement, with moderate effect sizes. Conclusions: This study suggests that peers can effectively deliver pain self-management strategies to other veterans with pain. Although this was a pilot study with a relatively short intervention period, patients improved on several outcomes.
• Stahl, S. M., Yaggi, H. K., Taylor, S., Qin, L., Ivan, C. S., Austin, C., Ferguson, J., Radulescu, R., Tobias, L., Sico, J., Vaz Fragoso, C. A., Williams, L. S., Lampert, R., Miech, E. J., Matthias, M. S., Kapoor, J., & Bravata, D. M. (2015). Infarct location and sleep apnea: Evaluating the potential association in acute ischemic stroke. Sleep Medicine, 16(Issue 10). doi:10.1016/j.sleep.2015.07.003
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  Background: The literature about the relationship between obstructive sleep apnea (OSA) and stroke location is conflicting with some studies finding an association and others demonstrating no relationship. Among acute ischemic stroke patients, we sought to examine the relationship between stroke location and the prevalence of OSA; OSA severity based on apnea-hypopnea index (AHI), arousal frequency, and measure of hypoxia; and number of central and obstructive respiratory events. Methods: Data were obtained from patients who participated in a randomized controlled trial (NCT01446913) that evaluated the effectiveness of a strategy of diagnosing and treating OSA among patients with acute ischemic stroke and transient ischemic attack. Stroke location was classified by brain imaging reports into subdivisions of lobes, subcortical areas, brainstem, cerebellum, and vascular territory. The association between acute stroke location and polysomnographic findings was evaluated using logistic regression for OSA presence and negative binomial regression for AHI. Results: Among 73 patients with complete polysomnography and stroke location data, 58 (79%) had OSA. In unadjusted models, no stroke location variable was associated with the prevalence or severity of OSA. Similarly, in multivariable modeling, groupings of stroke location were also not associated with OSA presence. Conclusions: These results indicate that OSA is present in the majority of stroke patients and imply that stroke location cannot be used to identify a group with higher risk of OSA. The results also suggest that OSA likely predated the stroke. Given this high overall prevalence, strong consideration should be given to obtaining polysomnography for all ischemic stroke patients.
• Edmonds, B. T., McKenzie, F., Fadel, W. F., Matthias, M. S., Salyers, M. P., Barnato, A. E., & Frankel, R. M. (2014). Using simulation to assess the influence of race and insurer on shared decision making in periviable counseling. Simulation in Healthcare, 9(Issue 6). doi:10.1097/sih.0000000000000049
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  Introduction: Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision making (SDM) in periviable counseling. Methods: Weconducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled 2 consecutive standardized patients diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation.We assessed verisimilitude of the simulation in semistructured debriefing interviews. Wecoded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework and then compared communication scores by standardized patient race and insurer using analysis of variance. Results: Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% were married, and 75% were parents; 91% of the physicians rated the simulation as highly realistic. Overall, SDMscores were relatively high,with means ranging from 6.4 to 7.9 (of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (P G 0.01 and P = 0.01, respectively). Between-group comparison revealed nonsignificant differences (P = G0.10) between the SDM scores for privately insured black patients versus privately insured white patients, Medicaid-insured white patients versus Medicaid-insured black patients, and privately insured black patients versus Medicaid-insured black patients. Conclusions: This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. Shared decision making may occur differentially based on patients' sociodemographic characteristics and deserves further study.
• Fukui, S., Salyers, M. P., Matthias, M. S., Collins, L., Thompson, J., Coffman, M., & Torrey, W. C. (2014). Predictors of shared decision making and level of agreement between consumers and providers in psychiatric care. Community mental health journal, 50(Issue 4). doi:10.1007/s10597-012-9584-0
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  The purpose of this study was to quantitatively examine elements of shared decision making (SDM), and to establish empirical evidence for factors correlated with SDM and the level of agreement between consumer and provider in psychiatric care. Transcripts containing 128 audio-recorded medication check-up visits with eight providers at three community mental health centers were rated using the Shared Decision Making scale, adapted from Braddock's Informed Decision Making Scale (Braddock et al. 1997, 1999, 2008). Multilevel regression analyses revealed that greater consumer activity in the session and greater decision complexity significantly predicted the SDM score. The best predictor of agreement between consumer and provider was "exploration of consumer preference," with a four-fold increase in full agreement when consumer preferences were discussed more completely. Enhancing active consumer participation, particularly by incorporating consumer preferences in the decision making process appears to be an important factor in SDM.
• Hirsh, A. T., Hollingshead, N. A., Bair, M. J., Matthias, M. S., & Kroenke, K. (2014). Preferences, experience, and attitudes in the management of chronic pain and depression: A comparison of physicians and medical students. Clinical Journal of Pain, 30(Issue 9). doi:10.1097/ajp.0000000000000035
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  OBJECTIVES:: The current study investigated clinicians' treatment preferences for chronic pain and depression and the extent to which these preferences were related to clinicians' experience and attitudes. METHODS:: Eighty-five participants (50 physicians, 35 medical students) made treatment recommendations for 8 virtual patients with chronic low back pain and depression. The 10 treatment options included pharmacological and nonpharmacological approaches. Participants also provided information about their clinical experience and completed measures assessing their attitudes toward patients with pain and depression. RESULTS:: The highest recommended treatments were over-the-counter medications and topical modalities, whereas "no intervention," referral to a pain specialist, and opioid medication received the lowest ratings. Physicians gave higher ratings to physical therapy (P
• Hirsh, A. T., Hollingshead, N. A., Matthias, M. S., Bair, M. J., & Kroenke, K. (2014). The influence of patient sex, provider sex, and sexist attitudes on pain treatment decisions. Journal of Pain, 15(Issue 5). doi:10.1016/j.jpain.2014.02.003
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  Research suggests that patient sex, provider sex, and providers' sexist attitudes interact to influence pain care; however, few empirical studies have examined these influences. We investigated sex (patient and provider) differences in pain treatment and the extent to which providers' sexist attitudes were associated with these differences. Ninety-eight health care providers (52% female) completed the Ambivalent Sexism Inventory and made treatment ratings for 16 computer-simulated patients with low back pain. Patient sex was balanced across vignettes. Results indicated that female patients received significantly higher antidepressant (F[1, 96] = 4.51, P
• Krebs, E. E., Bergman, A. A., Coffing, J. M., Campbell, S. R., Frankel, R. M., & Matthias, M. S. (2014). Barriers to guideline-concordant opioid management in primary care - A qualitative study. Journal of Pain, 15(Issue 11). doi:10.1016/j.jpain.2014.08.006
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  Prior studies have demonstrated poor physician adherence to opioid management guidelines in primary care. The objectives of this qualitative study were to understand physicians' and patients' perspectives on recommended opioid management practices and to identify potential barriers to and facilitators of guideline-concordant opioid management in primary care. Individual semistructured interviews were conducted with 14 primary care physicians and 26 of their patients receiving long-term opioid therapy. Data were analyzed using a qualitative immersion/crystallization approach. We identified 3 major barriers to and 1 facilitator of use of recommended opioid management practices. Major barriers were inadequate time and resources available; relying on general impressions of risk for opioid misuse; and viewing opioid monitoring as a "law enforcement" activity. The third barrier was most apparent for physicians in the context of drug testing and for patients in the context of opioid agreements. Beliefs about the need to protect patients from opioid-related harm emerged as a major facilitator, especially among patients.We hypothesize that future interventions to improve opioid management in primary care will be more effective if they address identified barriers and use a patientcentered framework, in which prevention of opioid-related harm to patients is emphasized as the primary goal. Perspective: This article describes primary care perspectives on guideline-recommended opioid management practices. Barriers identified in this study may contribute to underuse of recommended opioid management practices. Consideration of barriers and facilitators to guideline-concordant care could improve effectiveness of future interventions aimed at improving opioid management in primary care.\.
• Matthias, M. S. (2014). A qualitative study of chronic pain in Operation Enduring Freedom/Operation Iraqi Freedom veterans: "A burden on my soul". Military medicine, 179(Issue 1). doi:10.7205/milmed-d-13-00196
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  OBJECTIVES: Over half of the veterans returning from the conflicts in Iraq and Afghanistan are burdened with chronic pain. Although these young veterans may have to live with pain for the rest of their lives, little is known about the struggles this new group of veterans faces, or their perceptions of support from family, friends, and others. The purpose of this study is to understand Operation Enduring Freedom/Operation Iraqi Freedom veterans' experiences with chronic pain and social support. METHODS: In-depth qualitative interviews were conducted with veterans who participated in an intervention for chronic pain. Grounded theory guided data analysis. RESULTS: Veterans described a range of emotions associated with chronic pain, including hopelessness, anger, and fear that their pain would worsen. For some, talking about their pain was helpful, but others avoided talking about their pain, often because people did not understand or overreacted. CONCLUSION: Although support from friends and family is often effective, veterans and others with chronic pain are uniquely positioned to offer support to others with pain. Clinically, an approach to pain management in which veteran peers are integrated into chronic pain treatment approaches, similar to the Veterans Affairs' mental health model of care, might offer additional benefits for veterans with chronic pain.
• Matthias, M. S., Chumbler, N. R., Bravata, D. M., Yaggi, H. K., Ferguson, J., Austin, C., McClain, V., Dallas, M. I., Couch, C. D., Burrus, N., & Miech, E. J. (2014). Challenges and Motivating Factors Related to Positive Airway Pressure Therapy for Post-TIA and Stroke Patients. Behavioral Sleep Medicine, 12(Issue 2). doi:10.1080/15402002.2013.778200
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  Challenges adapting to continuous positive airway pressure (CPAP) therapy are largely unexplored in patients with stroke or transient ischemic attack. This study, nested within a randomized controlled trial of CPAP use, employed qualitative methods to explore challenges and motivators related to CPAP at two time points: prior to initiating therapy and at a 1-month follow up. Emergent thematic analysis, an inductive, qualitative approach, revealed variations in how patients experienced and adapted to CPAP across five phases: (a) interpreting the sleep apnea diagnosis, (b) contemplating CPAP therapy, (c) trying CPAP therapy, (d) making mid-course adjustments, and (e) experiencing benefits from CPAP therapy. Patients all had mild to moderate sleep apnea, and frequently did not experience sleep apnea symptoms. A salient motivator for adhering to CPAP therapy for these patients was the desire to reduce the risk of subsequent cerebrovascular events. Self-determination theory guided the interpretation of results. © 2014 Copyright Taylor and Francis Group, LLC.
• Matthias, M. S., Fukui, S., Kukla, M., Eliacin, J., Bonfils, K. A., Firmin, R. L., Oles, S. K., Adams, E. L., Collins, L. A., & Salyers, M. P. (2014). Consumer and relationship factors associated with shared decision making in mental health consultations. Psychiatric Services, 65(Issue 12). doi:10.1176/appi.ps.201300563
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  Objective: This study explored the association between shared decision making and consumers' illness management skills and consumerprovider relationships. Methods: Medication management appointments for 79 consumers were audio recorded. Independent coders rated overall shared decision making, minimum level of shared decision making, and consumer-provider agreement for 63 clients whose visit included a treatment decision. Mental health diagnoses, medication adherence, patient activation, illness management, working alliance, and length of consumerprovider relationships were also assessed. Correlation analyses were used to determine relationships among measures. Results: Overall shared decision making was not associated with any variables.Minimum levels of shared decision making were associated with higher scores on the bond subscale of the Working Alliance Inventory, indicating a higher degree of liking and trust, and with better medication adherence. Agreement was associated with shorter consumer-provider relationships. Conclusions: Consumerprovider relationships and shared decision makingmight have amore nuanced association than originally thought.
• Matthias, M. S., Krebs, E. E., Bergman, A. A., Coffing, J. M., & Bair, M. J. (2014). Communicating about opioids for chronic pain: A qualitative study of patient attributions and the influence of the patient-physician relationship. European Journal of Pain (United Kingdom), 18(Issue 6). doi:10.1002/j.1532-2149.2013.00426.x
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  Background Chronic pain poses numerous challenges for patients and providers, particularly when opioid treatment is discussed. Despite accounts of antagonistic patient-provider communication, little is known about how communication about opioids unfolds during clinic visits and, importantly, how the relationship history of a patient and physician shapes this communication. This study's objective was to advance understanding of communication about opioid treatment by recording primary care clinic visits and conducting in-depth interviews with patients to gain insight into the patient-provider relationship and its influence on clinical communication. Methods Forty patients with chronic pain were audio recorded during their primary care clinic appointments and then interviewed about their pain care and relationships with their providers. Ten patients were excluded from analysis because pain was not discussed during the clinic visit. Results Qualitative analysis revealed that patients responded in markedly different ways to similar physician treatment decisions about opioids. Some patients attributed limiting or denying opioids to physicians' distrust or lack of caring. Others attributed these limitations to acting out of genuine concern for patients' health. These attributions appeared to be shaped by features of the patient-physician relationship as described by patients. Results are discussed within the framework of attribution theory. Conclusions Understanding how patients and providers discuss opioid treatment is critical for optimal pain treatment. Physicians might be able to improve communication by re-framing treatment discussions about opioids around external factors, such as benefits and harms, and engaging in communication that fosters a strong therapeutic alliance and emphasizes concern for the patient. © Published 2013. This article is a U.S. Government work and is in the public domain in the USA.
• Saleem, J. J., Flanagan, M. E., Russ, A. L., McMullen, C. K., Elli, L., Russell, S. A., Bennett, K. J., Matthias, M. S., Rehman, S. U., Schwartz, M. D., & Frankel, R. M. (2014). You and me and the computer makes three: Variations in exam room use of the electronic health record. Journal of the American Medical Informatics Association, 21(Issue 2). doi:10.1136/amiajnl-2013-002189
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  Challenges persist on how to effectively integrate the electronic health record (EHR) into patient visits and clinical workflow, while maintaining patient-centered care. Our goal was to identify variations in, barriers to, and facilitators of the use of the US Department of Veterans Affairs (VA) EHR in ambulatory care workflow in order better to understand how to integrate the EHR into clinical work. We observed and interviewed 20 ambulatory care providers across three geographically distinct VA medical centers. Analysis revealed several variations in, associated barriers to, and facilitators of EHR use corresponding to different units of analysis: computer interface, team coordination/workflow, and organizational. We discuss our findings in the context of different units of analysis and connect variations in EHR use to various barriers and facilitators. Findings from this study may help inform the design of the next generation of EHRs for the VA and other healthcare systems.
• Bergman, A. A., Matthias, M. S., Coffing, J. M., & Krebs, E. E. (2013). Contrasting tensions between patients and pcps in chronic pain management: A qualitative study. Pain Medicine (United States), 14(Issue 11). doi:10.1111/pme.12172
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  Objective: With greater scrutiny on primary care providers' (PCPs) approaches to chronic pain management, more research is needed to clarify how concerns and uncertainties about opioid therapy affect the ways both patients with chronic pain and PCPs experience primary care interactions. The goal of this qualitative study was to develop a better understanding of the respective experiences, perceptions, and challenges that patients with chronic pain and PCPs face communicating with each other about pain management. Design: Purposive and snowball sampling techniques were used to identify 14 PCPs. Patients who received ≥6 opioid prescriptions during the prior year were selected at random from the panels of participating physicians. Face-to-face in-depth interviews were conducted individually with patients and PCPs. Setting: VISN 11 Roudebush VA Medical Center (RVAMC) in Indianapolis, Indiana. Subjects: Fourteen PCPs and 26 patients with chronic pain participated. Methods: An inductive thematic analysis was conducted separately with patient and PCP interview data, after which the emergent themes for both groups were compared and contrasted. Results: Three notable tensions between patients and PCPs were discovered: 1) the role of discussing pain versus other primary care concerns, 2) acknowledgment of pain and the search for objective evidence, and 3) recognition of patient individuality and consideration of relationship history. Conclusions: Competing demands of primary care practice, differing beliefs about pain, and uncertainties about the appropriate place of opioid therapy in chronic pain management likely contributed to the identified tensions. Several clinical communication strategies to help PCPs mitigate and manage pain-related tensions are discussed. This article is a U.S. Government work and is in the public domain in the USA.
• Frankel, R. M., Salyers, M. P., Bonfils, K. A., Oles, S. K., & Matthias, M. S. (2013). Agenda setting in psychiatric consultations: An exploratory study. Psychiatric Rehabilitation Journal, 36(Issue 3). doi:10.1037/prj0000004
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  Objective: Patient- or consumer-centeredness has been recognized as a critical component of quality in primary health care, but is only beginning to be recognized and studied in mental health. Among the first opportunities to be consumer-centered is collaboratively producing an agenda of topics to be covered during a clinic visit. Early agenda setting sets the stage for what is to come and can affect the course, direction, and quality of care. The purpose of this work is to study agenda setting practices among 8 prescribers (5 psychiatrists and 3 nurse practitioners) at the beginning of their encounters with 124 consumers diagnosed with schizophrenia spectrum disorders (56%), bipolar disorder (23%), major depression (15%), and other disorders (6%). Method: We modified an extant agenda-setting rubric by adding behaviors identified by a multidisciplinary team who iteratively reviewed transcripts of the visit openings. Once overall consensus was achieved, two research assistants coded all of the transcripts. Twenty-five transcripts were scored by both raters to establish interrater reliability. Results: We identified 10 essential elements of agenda setting. Almost 10% of visits had no agenda set, and only 1 of 3 encounters had partial or complete elicitation of a single concern. Few additional concerns (4%) were solicited, and no encounter contained more than 6 essential elements. Conclusions and Implications for Practice: Collaborative agenda setting represents a unique opportunity to translate the concept of consumer-centeredness into mental health care. Initial results suggest the rating system is reliable, but the essential elements are not being used in practice. © 2013 American Psychological Association.
• Hirsh, A. T., Hollingshead, N. A., Bair, M. J., Matthias, M. S., Wu, J., & Kroenke, K. (2013). The influence of patient's sex, race and depression on clinician pain treatment decisions. European Journal of Pain (United Kingdom), 17(Issue 10). doi:10.1002/j.1532-2149.2013.00355.x
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  Background: Pain treatments often vary across patients' demographic and mental health characteristics. Most research on this topic has been observational, has focused on opioid therapy exclusively and has not examined individual differences in clinician decision making. The current study examined the influence of patient's sex, race and depression on clinicians' chronic pain treatment decisions. Methods: We used virtual human technology and lens model methodology to enhance study realism and facilitate a richer understanding of treatment decisions. Clinicians and trainees (n = 100) made treatment decisions (opioid, antidepressant, pain specialty referral, mental health referral) for 16 computer-simulated patients with chronic low back pain. Patients' sex, race and depression status were manipulated across vignettes (image and text). Results: Individual- and group-level analyses indicated that patient's depression status had the strongest and most consistent influence on treatment decisions. Although less influential overall, patient's sex and race were significantly influential for a subset of participants. Furthermore, the results indicated that participants who were influenced by patient's race had less experience in treating chronic pain than those who were not influenced by patient's race [t(11.59) = 4.75; p = 0.001; d = 1.20]. Conclusions: The results of this study indicated considerable variability in participants' chronic pain treatment decisions. These data suggest that interventions to reduce variability in treatment decision making and improve pain care should be individually tailored according to clinicians' decision profiles. © 2013 European Federation of International Association for the Study of Pain Chapters.
• Matthias, M. S., Krebs, E. E., Collins, L. A., Bergman, A. A., Coffing, J., & Bair, M. J. (2013). "I'm Not Abusing or Anything": Patient-physician communication about opioid treatment in chronic pain. Patient Education and Counseling, 93(Issue 2). doi:10.1016/j.pec.2013.06.021
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  Objective: To characterize clinical communication about opioids through direct analysis of clinic visits and in-depth interviews with patients. Methods: This was a pilot study of 30 patients with chronic pain, who were audio-recorded in their primary care visits and interviewed after the visit about their pain care and relationship with their physicians. Emergent thematic analysis guided data interpretation. Results: Uncertainties about opioid treatment for chronic pain, particularly addiction and misuse, play an important role in communicating about pain treatment. Three patterns of responding to uncertainty emerged in conversations between patients and physicians: reassurance, avoiding opioids, and gathering additional information. Results are interpreted within the framework of Problematic Integration theory. Conclusion: Although it is well-established that opioid treatment for chronic pain poses numerous uncertainties, little is known about how patients and their physicians navigate these uncertainties. This study illuminates ways in which patients and physicians face uncertainty communicatively and collaboratively. Practice implications: Acknowledging and confronting the uncertainties inherent in chronic opioid treatment are critical communication skills for patients taking opioids and their physicians. Many of the communication behaviors documented in this study may serve as a model for training patients and physicians to communicate effectively about opioids. © 2013.
• Matthias, M. S., Salyers, M. P., & Frankel, R. M. (2013). Re-thinking shared decision-making: Context matters. Patient Education and Counseling, 91(Issue 2). doi:10.1016/j.pec.2013.01.006
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  Objective: Traditional perspectives on shared decision-making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but also by the entire clinical encounter, and, even more broadly, by the nature of the patient-provider relationship.Method: The Four Habits Approach to Effective Clinical Communication, a validated and widely used framework for patient-provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient-provider relationship. Results: The Four Habits consists of four categories of behaviors: (1) invest in the beginning; (2) elicit the patient's perspective; (3) demonstrate empathy; and (4) invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM. Conclusion: SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions. Practice implications: SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework. © 2013.
• Salyers, M. P., Matthias, M. S., Sidenbender, S., & Green, A. (2013). Patient activation in schizophrenia: Insights from stories of illness and recovery. Administration and Policy in Mental Health and Mental Health Services Research, 40(Issue 5). doi:10.1007/s10488-012-0435-7
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  Using a mixed-methods approach, we sought a deeper understanding of patient activation in 46 participants with schizophrenia. We qualitatively examined narratives for themes related to patient activation and divided the sample based on the mental health version of the patient activation measure. Participants high in patient activation described acceptance, control over illness, a wide range of activities that help them, and highlighted collaborative treatment experiences. The groups did not differ in understanding the cause of illness, what makes symptoms worse, or things they were proud of. Active management of schizophrenia mirrors physical health activation in several ways. © 2012 Springer Science+Business Media, LLC (outside the USA).
• Schmid, A. A., Yaggi, H. K., Burrus, N., McClain, V., Austin, C., Ferguson, J., Fragoso, C., Sico, J. J., Miech, E. J., Matthias, M. S., Williams, L. S., & Bravata, D. M. (2013). Circumstances and consequences of falls among people with chronic stroke. Journal of Rehabilitation Research and Development, 50(Issue 9). doi:10.1682/jrrd.2012.11.0215
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  Falls are common after stroke; however, circumstances and consequences are relatively unknown. Our objectives were to identify the differences between fallers and non-fallers among people with chronic stroke, identify the circumstances of fall events, and examine the consequences of the falls. This is a secondary data analysis; all participants included sustained a stroke. Variables included demographics, stroke characteristics, and comorbidities. Falls were collected via self-report, and circumstances and consequences were derived from participant description of the event and categorized as appropriate. Among 160 participants, 53 (33%) reported a fall during the 1 yr period. Circumstances of falls were categorized as intrinsic or extrinsic. Location and circumstance of the fall were included: 70% occurred at home and 40% were associated with impaired physical or mental state (e.g., inattention to tying shoes). Additionally, 21% of falls were associated with activities of daily living and mobility and 34% with slips or trips. The majority who fell sustained an injury (72%). Injuries ranged from bruising to fractures, and 55% of those with an injury sought medical care (32% to emergency department). Poststroke falls are associated with an alarming rate of injury and healthcare utilization. Targeting mental and physical states may be key to fall prevention.
• Bravata, D. M., Ferguson, J., Miech, E. J., Agarwal, R., McClain, V., Austin, C., Struve, F., Foresman, B., Li, X., Wang, Z., Williams, L. S., Dallas, M. I., Couch, C. D., Sico, J., Fragoso, C., Matthias, M. S., Chumbler, N., Myers, J., Burrus, N., , Dube, A., et al. (2012). Diagnosis and treatment of sleep apnea in patients' homes: The rationale and methods of the "GoToSleep" randomized-controlled trial. Journal of Clinical Sleep Medicine, 8(Issue 1). doi:10.5664/jcsm.1654
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  Background: The "Diagnosis and Treatment of Sleep Apnea in Cerebrovascular Disease" (GoToSleep) study is evaluating a strategy to improve the diagnosis and treatment of sleep apnea among veterans with stroke or transient ischemic attack (TIA) who also have hypertension. Specifically, the GoToSleep study was designed to overcome some of the barriers that exist within the Veterans Health Administration (VHA) to the timely diagnosis and treatment of sleep apnea by using ambulatory home-based polysomnography and auto-titrating continuous positive airway pressure (CPAP) to reduce the reliance on laboratory-based sleep studies. Methods: The GoToSleep study is a prospective, multi-site, randomized, controlled strategy trial among an expected 318 veterans with cerebrovascular disease and hypertension who are assigned to an intervention group or a control group. Patients in the intervention group receive unattended polysomnography at baseline, and those with sleep apnea receive autotitrating CPAP therapy for up to one year. Patients in the control group receive usual care and unattended polysomnography at the end of the study to identify the rate of undiagnosed sleep apnea. The primary objectives of the GoToSleep study are to determine whether a diagnostic and therapeutic intervention strategy among veterans with cerebrovascular disease and hypertension improves: (1) detection of sleep apnea; (2) appropriate treatment for sleep apnea; and (3) control of hypertension. Twenty-four-hour blood pressure assessments are made at baseline and at the end of the one-year study period for both groups. Antihypertensive medications and their doses are recorded at the time of the 24-hour blood pressure measurements. Discussion: This manuscript provides the rationale for 4 key components of the design of the GoToSleep trial: the inclusion of patients with cerebrovascular disease and hypertension without the use of a measure of daytime sleepiness as an eligibility criterion; the use of portable polysomnography and auto-titrating CPAP in patients' homes rather than using sleep laboratory polysomnography with fixed pressure CPAP; the analytic approach to evaluating change in blood pressure in the context of change in antihypertensive medications; and the use of a usual care control group.
• Matthias, M. S., Miech, E. J., Myers, L. J., Sargent, C., & Bair, M. J. (2012). "There's more to this pain than just pain": How patients' understanding of pain evolved during a randomized controlled trial for chronic pain. Journal of Pain, 13(Issue 6). doi:10.1016/j.jpain.2012.03.007
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  Chronic pain is prevalent, is costly, and exerts an emotional toll on patients and providers. Little is known about chronic pain in veterans of the recent military conflicts in Afghanistan and Iraq (OEF/OIF/OND [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn] veterans). This study's objective was to ascertain veterans' perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (ESCAPE: Evaluation of Stepped Care for Chronic Pain). Qualitative interviews were conducted with patients in the intervention arm of ESCAPE. Questions related to veterans' experiences with trial components, overall perceptions of the intervention, strengths, and suggestions for improvement. Twenty-six veterans (21% of total intervention patients) participated. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity) and non-responders. Non-completers (completed
• Matthias, M. S., Miech, E. J., Myers, L. J., Sargent, C., & Bair, M. J. (2012). An Expanded View of Self-Management: Patients' Perceptions of Education and Support in an Intervention for Chronic Musculoskeletal Pain. Pain Medicine (United States), 13(Issue 8). doi:10.1111/j.1526-4637.2012.01433.x
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  Objectives. Chronic pain is prevalent, costly, and is associated with profound psychological effects. Although pain is prevalent in returning veterans of the recent military conflicts in Afghanistan and Iraq (Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn [OEF/OIF/OND] Veterans), little is known about chronic pain in these patients. This study's objective was to ascertain perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (Evaluation of Stepped Care for Chronic Pain [ESCAPE]). Design. Qualitative interviews were conducted with 26 patients in the intervention arm of ESCAPE (21% of total intervention patients) to determine patients' experiences with and perceptions of the intervention. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity), nonresponders, and noncompleters (completed
• Matthias, M. S., Salyers, M. P., Rollins, A. L., & Frankel, R. M. (2012). Decision making in recovery-oriented mental health care.. Psychiatric rehabilitation journal, 35(Issue 4). doi:10.2975/35.4.2012.305.314
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  Patient-centered communication has been linked to patient satisfaction, treatment adherence and outcomes. Shared decision making (SDM) has been advocated as an important and ethically essential aspect of patient-centered care, but SDM has received relatively little attention in mental health care, despite studies indicating that consumers want to be involved in making decisions. This is particularly important in a recovery-oriented system, where consumers are active participants in their treatment and rehabilitation. Because medication management is a key component of recovery from severe mental illnesses, this study explores how consumers and providers make decisions in medication management consultations. Four providers (3 psychiatrists, 1 nurse practitioner) and 40 consumers with severe mental illness (10 consumers per provider) were recruited from a community mental health center with a recovery-oriented focus. We directly observed 40 medication management appointments. Observations were audio recorded and transcribed. We used emergent thematic analysis to characterize decision making processes. Providers initiated most decisions, although they often invited consumers to participate in decision making. Decisions initiated by consumers elicited a greater degree of discussion and disagreement, but also frequently resulted in consumers' preferences prevailing. Consultations generally exhibited more characteristics of person-centeredness than SDM. While we observed a high degree of person-centeredness, SDM was not prevalent. Interventions helping consumers to take greater initiative when working with service providers may be helpful. For example, programs using tools such as peer instruction, Internet-based software, and individual case-manager instruction all have shown promise for enhancing SDM in mental health treatment. Further research is needed to determine the degree of SDM in other settings (e.g., with case managers) and the impact of SDM on consumers' recovery.
• Salyers, M. P., Matthias, M. S., Fukui, S., Holter, M. C., Collins, L., Rose, N., Thompson, J. B., Coffman, M. A., & Torrey, W. C. (2012). A coding system to measure elements of shared decision making during psychiatric visits. Psychiatric Services, 63(Issue 8). doi:10.1176/appi.ps.201100496
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  Objective: Shared decision making is widely recognized to facilitate effective health care. The purpose of this study was to assess the applicability and usefulness of a scale to measure the presence and extent of shared decision making in clinical decisions in psychiatric practice. Methods: A coding scheme assessing shared decision making in general medical settings was adapted to mental health settings, and a manual for using the scheme was created. Trained raters used the adapted scale to analyze 170 audio-recordings of medication check-up visits with either psychiatrists or nurse practitioners. The scale assessed the level of shared decision making based on the presence of nine specific elements. Interrater reliability was examined, and the frequency with which elements of shared decision making were observed was documented. The association between visit length and extent of shared decision making was also examined. Results: Interrater reliability among three raters on a subset of 20 recordings ranged from 67% to 100% agreement for the presence of each of the nine elements of shared decision making and 100% for the agreement between provider and consumer on decisions made. Of the 170 sessions, 128 (75%) included a clinical decision. Just over half of the decisions (53%) met minimum criteria for shared decision making. Shared decision making was not related to visit length after the analysis controlled for the complexity of the decision. Conclusions: The rating scale appears to reliably assess shared decision making in psychiatric practice and could be helpful for future research, training, and implementation efforts.
• Bair, M. J., & Matthias, M. S. (2011). Response to letter by Dr. Sciascia. Pain Medicine, 12(Issue 11). doi:10.1111/j.1526-4637.2011.01255.x
• Goering, E. M., & Matthias, M. S. (2010). Coping with chronic illness: Information use and treatment adherence among people with diabetes. Communication and Medicine, 7(Issue 2). doi:10.1558/cam.v7i2.107
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  This study's goal is to understand the complex relationship among information usage, medication adherence, and disease management in people with diabetes. Toward this end, we conducted 21 in-depth interviews with Type 2 diabetics. We queried patients on the sources and adequacy of information that they received about their disease, as well as on how closely they adhered to their prescribed medication regimen. Interviewees identified 12 sources of information that they used to varying degrees in managing their diabetes. Of these sources, patients relied most heavily on their doctors, particularly upon initial diagnosis, in spite of delivering mixed assessments of the adequacy of their physicians' provision of information. Other sources patients most frequently discussed included diabetes education programs, friends/family, the internet, the information leaflet that accompanies prescriptions and written information. Further, those who reported high adherence to their treatment regimen tended to rely on different sources than those who reported low adherence. Findings are interpreted within the framework of the Health Belief Model, and implications for designing effective interventions are discussed. Copyright © Equinox Publishing Ltd.
• Matthias, M. S. (2010). The impact of uncertainty on decision making in prenatal consultations: Obstetricians' and midwives' perspectives. Health Communication, 25(Issue 3). doi:10.1080/10410230903544977
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  This article examines decision making in prenatal consultations, how obstetricians (OBs) and midwives differ, and the role of uncertainty in these processes. Using participant-observation, comparative case-study methodology, pregnant women were observed and audio-recorded in their pre- and postnatal appointments, and in-depth, semistructured interviews were conducted with mothers and providers. Although decision-making processes appear similar between the OBs and midwives, closer analysis, employing problematic integration theory, reveals marked differences in providers' probabilistic and evaluative orientations that carry clear implications for both mothers and providers during pregnancy care. © Taylor & Francis Group, LLC.
• Matthias, M. S., & Bair, M. J. (2010). The patient-provider relationship in chronic pain management: Where do we go from here?. Pain Medicine, 11(Issue 12). doi:10.1111/j.1526-4637.2010.00998.x
• Matthias, M. S., Bair, M. J., Nyland, K. A., Huffman, M. A., Stubbs, D. L., Damush, T. M., & Kroenke, K. (2010). Self-Management Support and Communication from Nurse Care Managers Compared with Primary Care Physicians: A Focus Group Study of Patients with Chronic Musculoskeletal Pain. Pain Management Nursing, 11(Issue 1). doi:10.1016/j.pmn.2008.12.003
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  Pain is a critical health problem, with over half of Americans suffering from chronic or recurrent pain. Many patients also experience comorbid depression. Although numerous self-management interventions have been implemented in an effort to improve pain outcomes, little attention has been devoted to the role of the provider of these services, typically a nurse care manager (NCM). Given the robust literature pointing to a link between physician-patient communication and patient outcomes, NCM-patient communication merits closer examination. This paper reports chronic pain patients' perceptions of the communication with NCMs in a pain self-management trial and patients' perceptions of the communication they experienced in primary care. Eighteen patients suffering from chronic musculoskeletal pain and depression participated in four focus groups designed to ascertain their perceptions of the intervention. A key emergent theme from these focus groups was the contrast in patients' perceptions of the communication with their primary care physicians versus with the NCMs. Patients reported feeling supported, encouraged, and listened to by their NCMs, whereas they tended to be dissatisfied with their primary care physicians, citing issues such as lack of continuity of care, poor listening skills, and under- or overprescribing of medication. The results of this study underscore the importance of the NCM, particularly for patients with chronic conditions such as pain. © 2010 American Society for Pain Management Nursing.
• Matthias, M. S., Parpart, A. L., Nyland, K. A., Huffman, M. A., Stubbs, D. L., Sargent, C., & Bair, M. J. (2010). The Patient-Provider Relationship in Chronic Pain Care: Providers' Perspectives. Pain Medicine, 11(Issue 11). doi:10.1111/j.1526-4637.2010.00980.x
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  Background. Pain is the most commonly reported symptom in primary care and is a leading cause of disability. Primary care providers (PCPs) face numerous challenges in caring for patients with chronic pain including communication and relational difficulties.Objective. The objective of the study was to elicit providers' perspectives on their experiences in caring for patients with chronic pain.Design. The design used was a qualitative study using open-ended, in-depth interviews.Participants. Twenty providers (10 men, 10 women) from five different clinics were interviewed at the Roudebush Veterans Affairs Medical Center.Results. Three broad themes emerged from the analysis: 1) providers emphasized the importance of the patient-provider relationship, asserting that productive relationships with patients are essential for good pain care; 2) providers detailed difficulties they encounter when caring for patients with chronic pain, including feeling pressured to treat with opioids, believability of patients' reports of pain, worries about secondary gain/diversion, and "abusive" or "difficult" patients; and 3) providers described the emotional toll they sometimes felt with chronic pain care, including feeling frustrated, ungratified, and guilty.Findings. Findings were interpreted within a model of patient-centered care.Conclusions. The clinical implications of these findings are two-fold. First, PCPs' needs cannot be ignored when considering pain care. PCPs need support, both instrumental and emotional, as they care for patients with chronic pain. Second, improving PCPs' patient-centered communication skills-including demonstrating empathy and encouraging shared decision-making-holds promise for alleviating some of the strain and burden reported by providers, ultimately leading to improved patient care. © 2010 Wiley Periodicals, Inc.
• Bair, M. J., Matthias, M. S., Nyland, K. A., Huffman, M. A., Stubbs, D. W., Kroenke, K., & Damush, T. M. (2009). Barriers and facilitators to chronic pain self-management: A qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Medicine, 10(Issue 7). doi:10.1111/j.1526-4637.2009.00707.x
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  Objective: To identify barriers and facilitators to self-management of chronic musculoskeletal pain among patients with comorbid pain and depression. Design: A qualitative study using focus group methodology. Setting: Veteran Affairs (VA) and University primary care clinics. Patients: Recruited after participation in a clinical trial. Intervention: The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) trial tested an intervention of optimized antidepressant therapy combined with a pain self-management program versus usual care for primary care patients with comorbid chronic pain and depression. Outcome Measures: Thematic content analysis from focus group data was used to identify patient-perceived barriers and facilitators to self-management of chronic musculoskeletal pain. Results: Patients (N = 18) were 27 to 84 years old (M = 54.8), 61% women, 72% white, and 22% black. Barriers to pain self-management included: 1) lack of support from friends and family; 2) limited resources (e.g., transportation, financial); 3) depression; 4) ineffectiveness of pain-relief strategies; 5) time constraints and other life priorities; 6) avoiding activity because of fear of pain exacerbation; 7) lack of tailoring strategies to meet personal needs; 8) not being able to maintain the use of strategies after study completion; 9) physical limitations; and 10) difficult patient-physician interactions. Facilitators to improve pain self-management included 1) encouragement from nurse care managers; 2) improving depression with treatment; 3) supportive family and friends; and 4) providing a menu of different self-management strategies to use. Conclusions: Future research is needed to confirm these findings and to design interventions that capitalize on the facilitators identified while at the same time addressing the barriers to pain self-management. © American Academy of Pain Medicine.
• Matthias, M. S. (2009). Problematic integration in pregnancy and childbirth: Contrasting approaches to uncertainty and desire in obstetric and midwifery care. Health Communication, 24(Issue 1). doi:10.1080/10410230802607008
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  The experience of pregnancy is often accompanied by uncertainties with which mothers somehow have to cope. Uncertainty may be related to the health of the mother or baby, or how labor will be experienced, as well as longer-range issues, such as financial concerns and worries about being a good parent. Drawing on Babrow's (1992, 2007) PI (problematic integration) theory, this article explores the struggles that pregnant mothers face and the role that their practitioners play in these dilemmas. Particularly, this project examines obstetricians and midwives in an effort to discern how these providers differ in their confrontation of mothers' uncertainties.
• Salyers, M. P., Matthias, M. S., Spann, C. L., Lydick, J. M., Rollins, A. L., & Frankel, R. M. (2009). The role of patient activation in psychiatric visits. Psychiatric Services, 60(Issue 11). doi:10.1176/ps.2009.60.11.1535
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  Objective: This study identified ways that consumers of mental health services are active participants in psychiatric treatment. Methods: Four providers (three psychiatrists and one nurse practitioner) were recruited, and ten consumers with severe mental illness were recruited per provider (40 total). Consumers completed questionnaires on patient activation, illness self-management, and medication attitudes on the day of a psychiatric visit. The visit was audiotaped, transcribed, and thematically analyzed. Providers gave information on diagnosis, substance use disorder, and medication adherence. Results: Consumer-rated patient activation was positively related to illness self-management and negatively related to substance use disorder. Transcripts of the psychiatric visit showed that consumers were active in partnership building, seeking and displaying competence, and directing treatment; however, the relationship was weak between consumer-reported activation and observed activation behaviors. Conclusions: Consumers were found to be active participants in treatment in a variety of ways, but similar to other populations, the relationship between observed patient activation and consumer-reported desire for involvement was not direct.
• Matthias, M. S., & Babrow, A. S. (2007). Problematic integration of uncertainty and desire in pregnancy. Qualitative Health Research, 17(Issue 6). doi:10.1177/1049732307303241
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  Although most women in the United States choose physicians for their prenatal care, a small but growing number are now turning to midwives. The disparity between these two models of care has clear implications for the communication that takes place with each type of provider. In this project, the authors seek to understand the mother-midwife relationship by employing a case study approach with multiple data collection methods to examine one woman's struggles with the uncertainties she faces during her pregnancy. The authors employed problematic integration (PI) theory, which illuminates struggles with uncertainty, profound values, and communication, to examine how one woman and her midwife jointly handle and negotiate the dilemmas posed by her pregnancy. The woman's relationship and interactions with her midwife exemplify the midwifery model of care and illuminate the implications that this model has for the joint confrontation of uncertainty and desire during pregnancy. © 2007 Sage Publications.