Elsevier

Pain Management Nursing

Volume 16, Issue 6, December 2015, Pages 920-929
Pain Management Nursing

Original Article
Applying the RE-AIM Framework to Evaluate Integrative Medicine Group Visits Among Diverse Women with Chronic Pelvic Pain

https://doi.org/10.1016/j.pmn.2015.07.007Get rights and content

Abstract

The purpose of this study was to evaluate group medical visits using an integrative health approach for underserved women with chronic pelvic pain (CPP). We implemented an integrative medicine program to improve quality of life among women with CPP using Centering, a group-based model that combines healthcare assessment, education, and social support. Patients were from university-affiliated and public hospital-affiliated clinics. We evaluated the program with qualitative and quantitative data to address components of the RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Participants of the Centering CPP Program participants (n = 26) were demographically similar to a sample of women with CPP who sought care at Bay Area hospitals (n = 701). Participants were on average 40 years of age, a majority of whom were racial/ethnic minorities with low household income (76%). Women who attended four or more sessions (n = 16) had improved health-related quality of life, including decreases in average number of unhealthy days in the past month (from 24 to 18, p < .05), depressive symptoms (from 11.7 to 9.0, p < .05), and symptom severity (from 4.2 to 3.1, p < .01). Sexual health outcomes also improved (30.5 to 50.3, p = .02). No improvements were observed for pain catastrophizing. Our pilot program provides preliminary data that an integrative health approach using a group-based model can be adapted and implemented to reach diverse women with CPP to improve physical and psychological well-being. Given these promising findings, rigorous evaluation of implementation and effectiveness of this approach compared with usual care is warranted.

Introduction

Chronic pelvic pain (CPP), defined as cyclic or noncyclic pain below the umbilicus for at least 6 months (Williams, Hartmann, & Steege, 2004), severely impacts health-related quality of life (HRQOL) and affects at least 15% of adult women in the United States (Mathias, Kuppermann, Liberman, Lipschutz, & Steege, 1996). Common surgical and pharmaceutical approaches to CPP have limited effectiveness, especially over the long term (Andrews et al., 2012, Butrick, 2007). A comprehensive, interdisciplinary model of care addressing the range of medical and psychosocial aspects of CPP is recommended (Butrick, 2007, Daniels and Khan, 2010, Engeler et al., 2013, Fall et al., 2010, Gunter, 2003), but multidisciplinary pain clinics and integrative approaches are not accessible for most women with CPP (Howard, 2000). This unmet need is exacerbated among racial/ethnic minorities who have more severe pain-related symptoms and less adequate pain management compared with Whites (Green et al., 2003, Institute of Medicine, 2011).

Group medical visits (GMVs) may successfully address the challenges of providing comprehensive care for underserved patients with CPP by combining quality, efficient health care with educational support. GMVs, or shared medical appointments when patients with a similar condition simultaneously meet with clinicians for an extended period of time, have been used to provide ongoing care for various chronic conditions such as diabetes, pain, and asthma (Geller et al., 2011, Jaber et al., 2006, Maizels et al., 2003, Trento et al., 2002). Prior research suggests that GMVs may improve quality of life, self-efficacy, knowledge of disease, and patient satisfaction (Geller et al., 2011, Lorig et al., 2001, Scott et al., 2004); reduce healthcare utilization, such as emergency room and sub-specialist visits (Scott et al., 2004); and provide cost savings (Clancy, Cope, Magruder, Huang, & Wolfman, 2003).

The Centering model of GMVs emphasizes patient empowerment through the direct involvement of patients in their own health care, peer education, and group support and may be particularly appropriate for women with CPP (Chao, Abercrombie, & Duncan, 2012). Rigorous evaluation of Centering has demonstrated its efficacy in prenatal care where it has been associated with better birth outcomes, increased adequacy of care, and increased knowledge and satisfaction with care among pregnant women (Lathrop, 2013). It has also been implemented among patients with chronic conditions such as diabetes (DeFrancesco & Rising, 2010). We developed a GMV curriculum entitled “Centering CPP” that combines the Centering model of GMVs with integrative medicine modalities. For this study, we evaluated the process and outcomes of implementing the Centering CPP program based on RE-AIM, a framework used to assess multiple dimensions of chronic care interventions to inform program planning (Glasgow et al., 2006a, Glasgow et al., 2006b, Glasgow et al., 1999, Green and Glasgow, 2006). Our focus was primarily on Reach and Effectiveness, with Adoption, Implementation, and Maintenance as secondary objectives.

Section snippets

Methods

The University of California, San Francisco, Committee on Human Research (institutional review board) reviewed and approved all of the study's procedures.

Reach

Of the 58 eligible women who were initially screened for the Centering CPP program, 36 women with CPP (62%) expressed initial interest and 26 enrolled in the study (45%). Participants averaged 40 years of age (range 23-63 years) and were from diverse racial/ethnic backgrounds with 28% Latina, 24% non-Latina White, 32% African American, 8% Asian, and 8% classified as “other” race/ethnicity. Half had graduated from college, and 76% had incomes of less than $50,000 (Table 1). We assessed the

Discussion

Our study intervention, Centering CPP, was designed to reduce barriers to pain care, particularly for underserved patients; to foster patient self-management of pain through education and materials on pain and self-help strategies; and to provide consistent and thorough pain assessments, which are among the clinical care recommendations of the Institute of Medicine's (2011) comprehensive report, Relieving Pain in America. Engaging in self-management of symptoms and having a broad set of tools

Conclusions

The optimal model of care for women with CPP must take into account the complexity of this chronic condition and be aligned with the needs of each woman. In addition, reach, adoption, and implementation are important considerations to assess a new program's feasibility on individual and setting levels. Centering CPP is an innovative, group-based model of health care that may address some of the challenges in the treatment and management of CPP. We found that an integrative health approach

Acknowledgments

We thank our colleague Margy Hutchison, CNM for training, feedback, and support; Sharon Rising, CNM and the Centering Healthcare Institute for developing and disseminating an empowerment-focused model of group-based health care; Good Samaritan Family Resource Center for providing space to hold the groups; staff at the Women's Clinic at SFGH for supporting the study and recruitment efforts; our program co-facilitators Carmen Herlihy, LVN, Romina Santos, LVN, Zoraida McNulty, RN, and Katherine

References (44)

  • S.D. Mathias et al.

    Chronic pelvic pain: Prevalence, health-related quality of life, and economic correlates

    Obstetrics & Gynecology

    (1996)
  • S.S. Rising

    Centering pregnancy. An interdisciplinary model of empowerment

    Journal of Nurse-Midwifery

    (1998)
  • D.C. Turk et al.

    Core outcome domains for chronic pain clinical trials: IMMPACT recommendations

    Pain

    (2003)
  • J. Andrews et al.

    Noncyclic chronic pelvic pain therapies for women: Comparative effectiveness. (prepared by the Vanderbilt Evidence-based Practice Center under contract no. 290-2007-10065-i.) AHRQ Publicaton No. 11(12)-EHC088-EF

    (2012)
  • C.W. Butrick

    Chronic pelvic pain: How many surgeries are enough?

    Clinical Obstetrics and Gynecology

    (2007)
  • Centers for Disease Control and Prevention. (2011). Health-related quality of life methods and measures. Retrieved...
  • D.E. Clancy et al.

    Evaluating concordance to American Diabetes Association standards of care for type 2 diabetes through group visits in an uninsured or inadequately insured patient population

    Diabetes Care

    (2003)
  • L. Culley et al.

    The social and psychological impact of endometriosis on women's lives: A critical narrative review

    Human Reproductive Update

    (2013)
  • J. Daniels et al.

    Chronic pelvic pain in women

    British Medical Journal

    (2010)
  • M.S. DeFrancesco et al.

    A new way to be ‘patient-centered’ and help your practice

    The Female Patient

    (2010)
  • B.L. Fredrickson et al.

    What good are positive emotions in crises? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001

    Journal of Personality and Social Psychology

    (2003)
  • R.E. Glasgow et al.

    Evaluating the impact of health promotion programs: Using the RE-AIM framework to form summary measures for decision making involving complex issues

    Health Education Research

    (2006)
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    Support for the study was provided through the William K. Bowes Jr. Fund for Innovative Research in Integrative Medicine, the National Center for Complementary and Alternative Medicine (K01AT006545 and K01AT005270), and the National Center for Advancing Translational Sciences (KL2TR00143).

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