Original ArticleApplying the RE-AIM Framework to Evaluate Integrative Medicine Group Visits Among Diverse Women with Chronic Pelvic Pain
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
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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).