Layers of complexity: a directed content analysis of implementation determinants for integrative group medical visits for patients with chronic pain in safety-net primary care.

backgroundChronic pain impacts a quarter of U.S. adults and is pervasive among populations who rely on safety-net settings (e.g., hospital outpatient clinics and Federally Qualified Health Centers) for chronic pain management. These settings provide care to more than 31 million patients in the US annually, many of whom require ongoing management of chronic pain. Integrative Group Medical Visits (IGMVs) offer a potentially effective and cost-efficient approach to chronic pain management. The purpose of this study was to identify implementation determinants of IGMVs for chronic pain in safety-net settings to inform strategies to speed future scale-up.

methodsWe conducted semi-structured interviews with clinicians, administrators, and staff with experience implementing IGMVs for patients with chronic pain in safety-net settings. Interviews were guided by the updated Consolidated Framework for Implementation Research (CFIR), which also informed the codebook for directed content analysis of interview transcripts.

resultsA total of 21 interview participants were recruited from ten safety-net settings across the U.S., including clinicians, administrators, staff, and an evaluator. Findings related to 12 CFIR constructs were identified in the analysis, with 2 to 3 constructs identified per CFIR domain. In the Innovation domain, we found that IGMVs are adaptable, complex, incur up-front costs to implement, and yield long-term savings. In the Outer Setting domain, epidemics influence uptake and delivery of IGMVs, and novel financing approaches may facilitate implementation. In the Inner Setting domain, partnerships/connections and tension for change facilitated IGMV implementation; lack of compatibility with setting workflows was a barrier. In the Individual domain, implementation is driven by the motivation of clinician-advocates, and Group Visits Coordinators enhance delivery. In the Implementation Process domain, participants reported engaging clinicians and patients in recruitment, accessing training for clinicians, and adapting for telehealth delivery.

conclusionsWhile many findings were consistent with previous literature, we identified novel determinants: the complexity of IGMVs; the critical role and motivation of clinician-advocates; and importance of accessing training for innovation deliverers. Developing strategies informed by complexity theory that address these determinants is essential to scaling-up IGMVs in safety-net settings with the goal of increasing access to high-quality care and reducing suffering from chronic pain conditions.