Light Shed on Pain, Pain Care in Veterans

VBCR - June 2016, Vol 5, No 3 - Pain Management
Sophie Granger

Painful and expensive to manage, musculoskeletal disorders (MSDs) are among the most common disorders found in veterans and active duty personnel. According to a recent report from researchers behind a cohort designed to shed more light on this patient population, >50% of all veterans receiving care from the Veterans Health Administration (VHA) have been diagnosed with MSDs, and that the number is increasing annually.

Limited data are available on the characteristics of patients with MSDs, including their comorbidities, and whether rates of non-MSD comorbidities vary by levels of reported pain. In response to a request from the Institute of Medicine, and because epidemiologic data on the incidence, prevalence, and consequences of MSDs are scarce, Joseph L. Goulet, PhD, MS, Pain, Research, Informatics, Multi-morbidities, & Education Center, VA Connecticut Healthcare System, West Haven, and colleagues developed the MSD Cohort to improve the existing literature on painful disorders. In this report, the authors provide results of an analysis of the cohort, comparing patient characteristics across cohort entry years.

Three of the primary goals of the MSD Cohort were to generate a comprehensive registry of veterans who have MSD diagnoses and receive care at the VHA, the largest integrated healthcare system in the United States; evaluate variation in pain treatment and outcomes across varying demographic groups, geographic regions, and facilities; and estimate the costs of pain care in this patient population. In describing why the VHA is an ideal resource for data to address concerns in this patient population, the authors behind the MSD Cohort stated that, in addition to having one of the most comprehensive electronic health record systems in the United States, the VHA keeps numerous disease-specific cohorts and registries that support research and quality improvement initiatives.

“These large, national longitudinal cohorts represent a census of VHA patients that avoids some of the problems of selected samples recruited for research studies or trials, and they provide a wealth of information for understanding chronic illness management,” Dr Goulet and colleagues explained. “Of particular importance, the large size and lengthy follow-up also allows for detection of rare events occurring after years of observation, as well as examination of relationships within small but important subgroups.”

Electronic health records of patients treated at the VHA were explored by the authors of the report to specifically locate those diagnosed with conditions such as joint, back, and neck disorders, and osteoarthritis, per the International Classification of Diseases, Ninth Revision, Clinical Modification. To be included in the cohort, patients had to have ≥2 outpatient visits within 18 months of each other, or 1 outpatient visit with an MSD diagnosis, from 2000 to 2011; the index date was defined by the first diagnosis.

Pain intensity numeric rating scale (NRS) scores, comorbid medical and mental health diagnoses, pain-related treatments, and other characteristics were collected retrospectively and prospectively for the 5,237,763 patients included in the cohort. Six percent of patients were women, 15% identified as black, 18% reported having severe pain (NRS ≥7) on the index date, and the mean age of the cohort was 59 years. The most common MSD diagnoses were for nontraumatic joint (27%), back (25%), and osteoarthritis (21%). Notably, the authors of the report found that patients entering the cohort in recent years had more simultaneous MSD diagnoses and higher NRS scores.

“Analyses reported here demonstrate the value of the MSD cohort as an opportunity to study complex interactions among socio-demographic and clinical characteristics of veterans with MSD, including the ability to examine changes over time,” Dr Goulet and colleagues concluded. “Given the large and comprehensive nature of the MSD cohort, there are many additional opportunities to examine, for example, pain among veterans aged ≥85, correlates of specific MSD such as temporomandibular disorders, variation in trajectories of pain by facility, the use of and outcomes associated with nonpharmacologic pain treatments.”

The authors assert that the MSD Cohort is a plentiful resource for collective, health service research relevant to pain.


  1. Goulet JL, Kerns RD, Bair M, et al. The musculoskeletal diagnosis cohort: examining pain and pain care among veterans. Pain. 2016 Mar 25. Epub ahead of print.
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