Disruption and sustainment of cognitive behavioral therapy for chronic pain in the Veterans Health Administration following the onset of the COVID-19 pandemic

Disruption and sustainment of cognitive behavioral therapy for chronic pain in the Veterans Health Administration following the onset of the COVID-19 pandemic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Disruption and sustainment of cognitive behavioral therapy for chronic pain in the Veterans Health Administration following the onset of the COVID-19 pandemic Alan McGuire, Mindy Flanagan, Jessica Coffing, Morgan Traylor, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3783148/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract The sustainability of evidence-based practices (EBPs) is a pressing issue for implementation science and healthcare systems. The COVID-19 pandemic and related policies severely strained healthcare systems, thus representing a key test of the sustainability of EBPs. The current study examined the sustainability of one EBP- cognitive-behavioral therapy for chronic pain (CBT-CP) - in the Veterans Health Administration. Changes in provision of CBT-CP after the onset of COVID-19 were examined both qualitatively, using administrative datasets, and qualitatively, through interviews with CBT-CP providers. Changes in total psychotherapy services were also examined for reference. Results indicated CBT-CP provision was substantially disrupted by COVID-19. Interviewees reported difficulties regarding engagement in virtual sessions, disruptions from the home environment, and logistical challenges. Results indicate specific pathways by which the pandemic may have negatively affected the sustainability of this EBP. cognitive behavioral therapy nonpharmacological pain care chronic pain veterans Figures Figure 1 Figure 2 Figure 3 Figure 4 Public Significance Statement This study examined the disruption of cognitive behavioral therapy for chronic pain- an evidence-based psychotherapy for chronic pain- based on the COVID-19 pandemic. Results point to the importance of supporting healthcare systems in sustaining evidence-based practices in the face of disruptions. Introduction Sustainability of EBPs (evidence-based practices), or the “continued use of program components…” is “one of the most significant translational research problems” [1]. While substantial research has focused on the barriers and facilitators of initial implementation of EBPs, research on long-term sustainment has lagged behind [2]. Sustainment is of particular importance to healthcare systems and stakeholders as substantial investment in EBP implementation is more easily justified by long-term use and benefits. Emerging research [1-3] indicates that sustainability involves complex interactions between contextual factors (e.g., factors related to the healthcare system) and the EBP itself, often including adaptations to the EBP over time. Despite important theoretical work regarding sustainability, empirical examinations of the effects of changing contextual factors on EBP sustainability are lacking. The COVID-19 pandemic represented a major disruption to healthcare systems in which EBPs are provided as well as rapid adaptations in response to changing conditions. Data has indicated healthcare disruptions were substantial and widespread, particularly for non-emergent services and care for chronic conditions [4].Whereas data on overall service provision has painted a clear picture of decreased service quantity and threats to quality, both immediately following the pandemic onset and in the ensuing months, more focused examinations on the sustainment of EBPs, including changes to reach (amount of EBP sessions offered) and how EBPs have been adapted to accommodate the changing healthcare setting, are crucial to understanding both EBP sustainability and the impact of COVID-19 on the quality of available services for patients. Importantly, while the disruptions associated with the COVID-19 pandemic may be exceptional in scope, they may provide valuable insights into the effects of more common healthcare system disruptions such as infrastructural changes, natural disasters, and smaller-scale public health emergencies. It is unclear how EBPs may fare relative to services in general in the face of such disruptions. On one hand, healthcare systems and providers may focus limited resources on practices known to work (i.e., EBPs). On the other hand, EBPs may provide particular barriers to sustainment in the context of service disruption. One predominant adaptation is the conversion to telehealth. For instance, the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States, issued a policy in March of 2020 calling for the maximization of telehealth to minimize community spread of COVID-19 [5]. Consequently, telehealth increased from 14% of total visits pre-pandemic to 58% in June of 2020 [4]. Research has supported the effectiveness of telehealth provision of EBPs [6, 7]; however, this research has focused on EBPs built for or carefully adapted to telehealth. Little is known about the rapid adaptation of EBPs to telehealth in response to a public health emergency. The current study focuses on one EBP- cognitive-behavioral therapy for chronic pain (CBT-CP). CBT-CP is a core EBP for the management of a range of chronic pain conditions and is considered the centerpiece of multidisciplinary pain management programs [8]. Numerous randomized controlled trials have supported CBT-CP’s salubrious effects on pain interference and pain catastrophizing [9-11]. For these reasons, CBT-CP is included in numerous guidelines for chronic musculoskeletal pain conditions and has been implemented system-wide in the VHA), the largest integrated healthcare system in the United States. In 2012, VHA initiated implementation of CBT-CP through its national implementing EBPs program [12]. The program includes rigorous training for therapists followed by case-led consultation. Early data indicated widespread training and implementation of CBT-CP with high fidelity to the model. The sustainment of CBT-CP during the COVID-19 pandemic is of particular importance given known disproportionate burden on people with chronic conditions, structural barriers to providing other evidence-based chronic pain treatments via telehealth (e.g., acupuncture, spinal manipulation, etc.), and the risks associated with increased opioid prescribing. The current study examined the change in CBT-CP reach (defined as both total number of CBT-CP sessions and percentage of therapy sessions classified as CBT-CP) and adoption (number of therapists providing CBT-CP) following the issuance of VHA’s COVID-19 policy. Total psychotherapeutic services provided by CBT-CP were also modeled as a reference. Additionally, the experiences of CBT-CP therapists adapting CBT-CP for widespread virtual provision as a result of these changes was explored. Taken together, results elucidate both the impact on an EBP’s sustainment in the face of rapidly changing contexts as well as mechanisms by which contextual changes are perceived to affect sustainment. Methods Sample Quantitative Sample: The study sample included therapists who completed the VHA official CBT-CP training and consultation process (n = 478). The sample was limited to those who delivered at least one CBT-CP session between 02/01/19 and 03/31/21 (n = 414; 86.6%). Additionally, because analyses focused on comparing CBT-CP delivery before and after the COVID-19 onset, the sample was further limited to therapists that had at least one appointment during February 2019 – February 2020 and March 2020 – March 2021, respectively (n = 384; 80.3%). This decision excluded therapists hired after the onset of COVID-19 as well as those that had left at some point prior to the COVID-19 pandemic. Qualitative sample : Potential interviewees were identified from the therapists described above who completed VHA training and provided at least one session of CBT-CP in the previous year. The sample was further limited to providers who had on average of at least four appointments a month (n=59). Finally, in accordance with VHA policy, the sample was limited to those whose medical center leadership responded to our request to contact providers at their facility (n=34). Measures and Procedures Psychotherapeutic visits were identified as visits provided by sample therapists with a procedural code indicating individual or group psychotherapy (see supplement for full list of codes). CBT-CP visits were defined as a subset of psychotherapy visits identified using an iterative algorithm developed for this project. The algorithm was revised based on chart-review validation. The final algorithm combines a SQL string search for terms specific to CBT-CP (e.g., “cognitive-behavioral therapy for chronic pain”) with procedural codes commonly associated with CBT-CP sessions (e.g., individual psychotherapy, behavioral health integration, etc.; see Supplemental Material). Chart reviews on a randomly selected subset of available cases (n=103 patients, 100 providers) indicated that the final algorithm demonstrated good sensitivity (72.9%) and excellent specificity (98.9%). Clinics were identified using VA stop codes, which are administrative codes used to designate clinical functional groups within which services are provided. Qualitative One study member (MT) conducted semi-structured interviews with participants. The interview guide focused on the disruption of CBT-CP services due to the COVID-19 pandemic and was based on framework for modifications of EBPs [13]. Interviews were conducted via video, audio recorded, and transcribed for analysis. Their average length was 30 minutes, with a range of 15 to 57 minutes. Analysis Quantitative: Descriptive statistics were calculated for monthly and total number of visits, CBT-CP sessions, percent of visits in specific clinics (PTSD, Mental Health, Substance Use Disorder, Biomedical, Integrative Care, Pain Specialty) and telehealth visits. These calculations were made per therapist and per month. Time since CBT training was calculated as March 1, 2020, minus date of CBT training and included in descriptive statistics. Wilcoxon signed rank test was used to establish whether therapists’ percentages of CBT-CP visits differed between February 2019 – February 2020 and March 2020 – March 2021. McNemar’s Test was conducted to compare proportion of therapists delivering CBT-CP pre- and post-pandemic. A single group interrupted time series was conducted to understand the impact of the COVID-19 pandemic on CBT-CP delivery; an identical model was run for total psychotherapy (minus CBT-CP visits) for reference purposes. Models were estimated using a repeated measures Generalized Estimating Equations approach with a negative binomial distribution appropriate to count data and a first-order autoregressive correlation structure. The model contained time (coded as a continuous variable starting at -13 for first month, 0 for March 2020, and 12 for last month), interruption (coded as 0 for pre-pandemic, 1 for March 2020 and after), and time since interruption (coded as a continuous variable, 0 for pre-pandemic and March 2020, 1 to 12 for months following). The following equation represents the time series model: Number of sessions = β0 + β1 * time + β2 * interruption + β3 * time since interruption + e Here, number of CBT sessions per month is the outcome; β0 represents the predicted number of CBT sessions prior to the interruption; β1 is the slope for number of CBT sessions prior to the interruption; β2 is the amount of change in number of CBT sessions immediately after the interruption; β3 is the change in slope for number of CBT sessions after the interruption. The output for this paper was generated using SAS software 9.4. Copyright © 2013 SAS Institute Inc. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA. Qualitative: Two experienced data analysts (AM, MT) conducted qualitative data analysis. Toward this end, the first grounded themselves in the data by reading full transcripts of interviews and recording memos on emergent themes and lessons learned. These memos facilitated creation of a codebook. As analysts continued to read transcripts, codes were combined, added, and deleted until the codebook was stable and consistent and both coders reached consensus. Both coders independently coded transcripts and results were compared, discrepancies were resolved and modifications to themes made. Once the codes/themes reached stability, one coder coded half the remaining interviews and the other coder reviewed results. Summaries were entered into matrices. Matrices were analyzed to understand within and across therapist themes. Themes were summarized and triangulated by comparison to original data. Data were managed in Microsoft Excel. Study procedures were approved by the Indiana University IRB and Richard L Roudebush VAMC Research and Development Committee. Results QUANTITATIVE RESULTS Sample Three hundred eighty-four CBT-CP trained therapists met inclusion criteria. Included therapists were predominately psychologists and averaged about four years since their CBT-CP training (Table 1). Therapists provided the plurality of CBT-CP session in general Mental Health Clinics, about a fifth in Integrative Care (mental health integrated within medical care clinics such as primary care), and less than 10% each for PTSD, Substance Use Disorder, Biomedical, or Pain Specialty clinics. For this observation period, therapists delivered a median of 1375 therapeutic sessions (IQR=933, 2001). The median number of CBT-CP sessions delivered per therapist was 48.5 (IQR=12.5, 138) during the period of interest. Of total sessions per therapist, the median rate of CBT-CP sessions delivered was 4.3% (IQR=1.1, 10.9) and ranged from 1% to 89%. Across all months, CBT-CP was delivered in 8.0% of all sessions. Pandemic Disruption All indicators pointed to disruption of CBT-CP delivery at the pandemic’s onset. Interrupted time-series analyses showed pre-pandemic month-to-month change in CBT-CP sessions was not different from zero (Table 2); however, at the time of the interruption in March 2020, the change in CBT-CP sessions was estimated as a 29.7% reduction from the previous month. Moreover, post-interruption growth was not significantly different from zero. Figure 1 displays predicted and actual total number of CBT-CP sessions by month across all providers. Additionally, the percentage of psychotherapy sessions identified as CBT-CP dropped from 9.4% of all psychotherapies pre-interruption to 8.2% following the pandemic onset (S = -6333, p = .004). Finally, the percentage of therapists providing any CBT-CP dropped from 94.3% (362/384) pre-pandemic to 88.3% (339/384) after onset ( X 2 (1) =7.90, p=.005; Figure 2). Total psychotherapy (excluding CBT-CP visits) demonstrated similar, albeit less severe, disruption. As shown in Table 3, prior to the COVID-19 pandemic, the rate of psychotherapy services was not changing month-to-month. At the time of the interruption in March 2020, the change in psychotherapy sessions was estimated as a 26.9% reduction from the previous month. After disruption, the rate of psychotherapy sessions was positive; for example, a 1% increase was estimated for April 2020 to May 2020. Figure 3 displays predicted and actual total number of sessions by month across all providers. QUALITATIVE RESULTS Sample Of the 34 providers contacted, 12 declined:1 due to being in a supervisory role and not providing CBT-CP and 11 due to lack of time. 11 providers did not respond to interview requests. The final sample consisted of 11 providers who completed interviews. Results During interviews, CBT-CP therapists described their experiences of delivering CBT-CP after the onset of COVID-19. Generally, such sustainment involved transitioning to video sessions. During this transition, therapists described several challenges to video delivery of CBT-CP. Concerns Regarding Engagement in Sessions While therapists generally thought virtual sessions increased access, they had concerns with patients’ engagement in sessions. One therapist noted, “The challenges that I saw, especially with [CBT-CP delivered in a] group, was having them actively participate and feel like there was this sense of accountability where they didn't need to turn off their camera .” (Participant 11) Another therapist doubted the engagement with group curriculum, stating: “I don't know how much they were using the handouts and the materials. I don't know how much they were following through on homework when we would do our check-in at the beginning of the next appointment. I generally did not get a lot of feedback even with direct questions about ‘Did you work on this? How did it go?’... I did not find that the protocol was as effective as far as consistency of people attending and the follow-through on actually doing the homework.” (Participant 5) Several therapists expressed concerns about group cohesion, e.g ., “I would say as a clinician though… having patients in a group in a room [is better] because that group dynamic really becomes part of the treatment itself.” And therapists feared virtual care inhibited natural dynamics and connection among group members: I think it became more psychoeducational. And I did feel like there was less interaction, especially if somebody would turn their camera off…I think that the engagement was more difficult… Yeah. It felt like it was a little more formal, you know. Typically, when I have in person groups there's a lot of joking and sometimes seeing veterans hang around after the group is over and… exchanging phone numbers. So, that went down a lot. I don't know if any of them made connections with each other through that. (Participant 8) Given these concerns, several therapists developed strategies to support group cohesion in the virtual environment. One therapist learned to utilize the virtual platform to facilitate participation: “And these kind of muting things, we figured out, and how to utilize the chat in groups to encourage participation with the group members, to allow for more sharing.” (Participant 6) Another therapist intentionally made space for personal connections between group members: What we did is recruit, like if you want to share and chat your phone number, you can. Because typically, they would do that in the lobby before or after group. But we don't have, I don't have a lobby, so, you know, at times, we would just as providers, one of us would just stay on for a few minutes afterwards to allow them to chat or just to type in the chat, kind of the informal kind of like connections, it would make outside of group. We built in a little bit of time before and after group for them to be able to do that. (Participant 6) Disruptions from the Home Environment Concerns with engagement sometimes emerged due to patients participating in therapy sessions from home. For example, one therapist commented on challenges that arise when patients have children at home during sessions. Some of them are just confounding issues that you can't necessarily get rid of like you're at home and you have little kids and your little kids are going to interrupt you no matter how many times we set rules and boundaries. Can I have this? Can I do this? They wanna come play with you. It's very hard to establish that when you're not in clinic in that kind of position. (Participant 5) Respondents emphasized other informalities of the home environment that can disrupt care: “I saw my share of shirtless veterans or people, you know, having to tell them you can't do this appointment while you're driving your car, you know, or walking around Walmart. So, you know, that's, I think those were the major issues.” (Participant 8) “But then like I had said before, being able to monitor the noises and manage the things that are going on behind our veterans.” (Participant 11) In contrast to the above challenges, one respondent noted that the home environment can also be advantageous: “That's even better because the patient is at home, and so, you have that ability to be able to see their environment, to help them with various boundaries, etc. that aren't always as in vivo, you know, when they're coming to see you in the office.” (Participant 9) Logistical Difficulties Logistical difficulties often made offering virtual services challenging, in general. Multiple providers spoke about the amount of extra preparation it took to transition to virtual (Participants 2, 3, 5, 6, and 11). Due to moving to a virtual setting the providers were no longer able to give patients the materials for group during their group time. To make sure that patients had the materials, providers either sent the group materials via digital means such as MyHealtheVet (VHA’s patient portal), or they printed the materials and mailed them to the veterans. Participant 6 below describes the time demand it took to get the materials to the veterans at home: We have to break apart the handout because we have to send it in two emails because there’s a megabyte limit on what we can send on MyHealtheVet, creating time to send packets in the mail, creating time to send off the packets that get printed, and approvals for that because, you know, large print jobs, you can’t just print them at the VA. You have to go and send them out as well, so. I would say like what I remember, and in talking with the psychology resident at that time, was the amount of administrative time demand to move the group to online. Screen sharing was an option but proved to be unreliable; one therapist described it like this: The other concern for that too is that when people join virtual appointments on their phone, even when you share screen, it’s gonna be too small for them to be able to read it. And so that creates an issue with their kind of following along like a, again, a cognitive session in particular for them to be able to follow along in the appointment. (Participant 5) Scheduling was another logistical hurdle that providers had to overcome. Providers spoke about themselves as well as their schedulers having trouble managing the multiple software programs and getting patients scheduled for virtual sessions (Participants 1, 2, 3, 5, and 8). So, certainly, there had to be some, you know, adjustment to new grids, and you know, how to kind of navigate your schedule, et cetera, and getting patients scheduled, and you know, making sure patients know that it’s a virtual appointment not an in-person appointment. … And then working with the virtual care manager …Or you know, they might be scheduled in [the electronic health record], but I don’t have a VVC [VA Video Connect] link, or the patients reporting not having a VVC link. And so, I think those may be some of the administrative strains. So, just a little bit more to pay attention to and organize. (Participant 2). Technical issues also troubled the providers. To resolve these issues, providers submitted technology consults for the patients, used clinical time to troubleshoot connectivity issues, and switched to a phone call. (Participants 2, 4, and 6). Discussion This study shows the notable disruptions in delivery of CBT-CP in VHA in the period following the onset of the COVID-19 pandemic and describes therapists’ perceptions of the challenges in sustaining CBT-CP after a rapid transition to a virtual format. Results of the interrupted time-series analysis demonstrated that both the number of CBT-CP sessions and CBT-CP sessions as a percentage of total session declined and fewer therapists provided CBT-CP post-pandemic compared to pre-pandemic. Moreover the number of CBT-CP sessions was not growing at a significant rate in the post-onset period. As a reference, total psychotherapy session (excluding CBT-CP sessions) dropped, albeit by a smaller percentage, at the pandemic onset and demonstrated significant positive growth in the post-onset period. Below, we conceptualize this disruption as a problem of sustainment and consider it in the context of the Integrated Sustainability Framework (ISF; Shelton et al., 2018). The ISF states sustainment is affected by “dynamic interactions among outer contextual factors, inner contextual or organizational factors, processes, intervention characteristics, and implementer characteristics” and allows for interactions between any and all factors. We postulate two pathways involving a subset of ISF factors (Fig. 4 ), supported by extant literature regarding the COVID-19 pandemic’s effects on healthcare delivery and our findings, that may explain the mechanisms by which the pandemic’s onset may have reduced CBT-CP sustainment. Pathway 1 starts with a change in policy (outer contextual factor) , the VHA policy in response to the COVID-19 pandemic mandating maximization of virtual care [ 5 ] and hypothesizes that the policy change led to adaptation (process) - the conversation of psychotherapy to virtual delivery- which decreased the perceived benefit (intervention characteristic) of CBT-CP, which eroded its sustainability . Several providers interviewed perceived virtual CBT-CP as less effective (and thus beneficial) than in-person CBT-CP. Therapists noticed a decrease in interactivity in the virtual format, including how engaged patients were in sessions. Additionally, in group sessions, providers noted the lack of interaction among group participants, which undermined the extent to which group cohesion, a contributor to effectiveness, could be established [ 14 ]. Moreover, another therapist expressed doubt regarding engagement with homework and worksheets, which has been shown as a moderator of effective CBT interventions [ 15 , 16 ]. Taken together, there is sufficient reason to suspect the adaptation of CBT-CP to virtual care may have led to decreased perceived benefit of the intervention and subsequently reduced its sustainability. Pathway 2 focuses on the interaction between the adaptation process and inner contextual factors . Substantial literature has documented how the COVID-19 pandemic strained organizational resources and staffing (inner contextual factors) [ 17 – 20 ]. In addition to the direct effects of the pandemic on these inner context factors, results from our interviews elucidated the strain the adaptation to virtual care placed on organizational resources. Therapist interviews highlighted the increased burden of scheduling processes, acclimate patients to virtual platforms, and manage distribution of materials. In their review of the sustainability literature, [ 2 ]) noted factors related to capacity, stability of the workforce, and competing demands were commonly associated with sustainment, thus supporting the relevance of these strains on the sustainability of CBT-CP. However, our interviews did not provide perspectives directly relevant to the mechanisms by which these inner contextual changes eventually led to decreased sustainability of CBT-CP. One reasonable speculation is that, given their overwhelming burden, many CBT-CP therapists chose not to convert CBT-CP to a virtual service and therefore stopped offering it. This hypothesis is supported by the decreased number of therapists providing CBT-CP following the pandemic onset. Both pathways above delineate the mechanisms by which the onset of the COVID-19 pandemic led to decreased sustainability of CBT-CP; however, it is unclear the degree to which CBT-CP was uniquely affected in comparison to psychotherapy, in general. While non-CBT-CP services were disrupted, the overall drop was somewhat less severe and services showed a significant post-disruption growth. One previous study [ 21 ] found therapists with a cognitive-behavioral orientation were disrupted more than psychodynamic therapists during the pandemic. Responding therapists provided little insight into impactful differences between CBT-CP and other psychotherapies. One respondent noted problem-solving was necessary to distribute CBT-CP materials to patients. In contrast to some other therapies, CBT-CP calls for the use of a manual, standardized educational material, and assessments. Some of these requirements may have made its conversion and provision in virtual care more difficult. Especially in such resource strained circumstances, even small additional burdens may have made the difference. Finally, CBT-CP differs from many psychotherapies in its targeted population and condition. While most psychotherapies target mental health conditions, CBT-CP deals with chronic pain. Patients with chronic pain require complex care and more time from the provider [ 22 , 23 ]. It is unclear from these data whether CBT-CP trained therapists shifted resources toward alternate treatments for chronic pain or away from patients with chronic pain altogether. While these analyses provide an important opportunity to examine sustainment during a naturally occurring disruption, results should be viewed in the context of their limitations. The interrupted time-series analyses are based on administrative data processed using an algorithm developed for this project that showed a non-negligible false positive rate. However, this rate did not differ before and after pandemic onset, indicating that while our rate of CBT-CP may be an overestimate, it should not change conclusions regarding disruptions. It should also be noted that the estimated post-disruption growth rate of CBT-CP was the same as non-CBT-CP psychotherapy but was not statistically greater than zero due to sample size, variance, or some combination thereof. Therefore, while the evidence that CBT-CP was disrupted more than other psychotherapies is robust, the conclusion that its post-onset recovery was worse should be viewed with caution. Finally, the qualitative data is limited by a small sample of therapists, all of whom did sustain CBT-CP following the pandemic onset. As with all qualitative data, the intent is not generalization; however, this sample has the additional caveat that the perspectives of therapists not sustaining CBT-CP are not captured. These findings provide valuable insights into the disruption of EBP sustainability from the COVID-19 pandemic. Moreover, our analyses suggest specific pathways by which the pandemic may have exerted its effects and grounds these pathways in established implementation science frameworks. Future research should test these hypothesized pathways prospectively and with other contexts and practices. Importantly, while the COVID-19 pandemic is unique in its scope, disruptions to healthcare systems such as reorganizations, staffing disruptions, and transitions such as changes to electronic health records systems are common. Therefore, future work is necessary to insulate EBPs from disruptions to ensure their sustainment in the face of disruptions. Table 1 Therapist characteristics (n = 384) Characteristic Statistic Psychologist (yes), n(%) 271/384, (70.6%) Years since CBT-CP training, mean(SD) 3.9 (2.0) Number of therapeutic Sessions delivered, median(IQR) 1375 (933, 2001) Number of CBT-CP sessions delivered, median (IQR) 48.5 (12.5, 138) Percentage of total sessions delivered that included CBT-CP, median (IQR) 4.3 (12.5, 138) Percentage of total sessions delivered by clinic, mean(SD): Mental Health 41.2 (38.1) Integrative Care 20.4 (34.8) Pain Specialty 8.3 (22.9) PTSD 6.4 (18.9) Biomedical 5.5 (19.5) Substance Use Disorder 5.1 (18.6) Note: CBT-CP = cognitive behavioral therapy for chronic pain; IQR = interquartile range; SD = standard deviation; PTSD = post-traumatic stress disorder Table 2 Summary results from Interrupted Time Series analysis predicting number of CBT-CP sessions (n = 9984 months) Parameter Estimate Standard Error Z p-value Intercept 1.63 0.11 15.06 < .001 Time -0.01 0.01 -0.87 .39 Interruption -0.35 0.06 -5.74 < .001 Time since interruption 0.02 0.02 1.80 .07 Table 3 Summary results from Interrupted Time Series analysis predicting number of psychotherapy sessions (n = 9984 months) Parameter Estimate Standard Error Z p-value Intercept 4.11 0.03 124.94 < .001 Time -0.003 0.003 -1.38 .17 Interruption -0.31 0.02 -13.42 < .001 Time since interruption 0.02 .0004 4.91 < .001 Declarations Ethics Approval and Consent to Participate: All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the Indiana University Institutional Review Board. Informed consent was obtained from all subjects prior to participation. Consent for Publication: Not Applicable Availability of Data and Materials: The United States Department of Veterans Affairs (VA) places legal restrictions on access to veteran’s health care data, which includes both identifying data and sensitive patient information. The analytic data sets used for this study are not permitted to leave the VA firewall without a Data Use Agreement. This limitation is consistent with other studies based on VA data. However, VA data are made freely available to researchers behind the VA firewall with an approved VA study protocol. For more information, please visit https://www.virec.research.va.gov or contact the VA Information Resource Center (VIReC) at vog.av@CeRIV. Competing Interests: The authors have no competing interests. Funding: This work was supported by a Department of Veterans Affairs Health Services Research and Development Award to Dr. McGuire (IIR 17-094). The sponsor had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Authors' Contributions: A.M. led the study and qualitative analyses. M.F., L.M., M.M., and M.K. assisted with project design. M.F., J. Coffing, M.T., L. M., N.H., M.K., and M.M. participated in qualitative analyses. N.H., M.T., and J. Carter provided project management. A.M. and M.F. wrote the main manuscript text. M.F., L.M., and J. Coffing designed and conducted the statistical analysis. M.F. prepared the figures. All authors reviewed the manuscript. Acknowledgements: Not Applicable Authors' Information: Not Applicable References Shelton, R.C. and M. Lee, Sustaining Evidence-Based Interventions and Policies: Recent Innovations and Future Directions in Implementation Science. Am J Public Health, 2019. 109 (S2): p. S132-s134. Wiltsey Stirman, S., et al., The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement Sci, 2012. 7 : p. 17. Glasgow, R.E., et al., RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health, 2019. 7 : p. 64. Heyworth, L., Kirsh, S., Zulman, D., Ferguson, J.M., Kizer, K.W., Expanding access through virtual care: the VA's early experience with Covid-19. NEJM Catalyst catalyst innovations in care delivery, 2020. 1 (4). Administration, V.H., COVID-19 Response Plan: Incident-Specific Annex to the VHA High Consequence Infection (HCI) Base plan . 2020: Affairs DoV, ed. 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Cordova, and E.A. Dedert, Cognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program. Psychol Serv, 2022. 19 (1): p. 95-102. Stewart, M.O., et al., National dissemination of cognitive-behavioral therapy for chronic pain in veterans: therapist and patient-level outcomes. Clin J Pain, 2015. 31 (8): p. 722-9. Miller, C.J., et al., The FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare. Implement Sci, 2021. 16 (1): p. 36. Burlingame, G.M., D.T. McClendon, and C. Yang, Cohesion in group therapy: A meta-analysis. Psychotherapy (Chic), 2018. 55 (4): p. 384-398. Lebeau, R.T., et al., Homework compliance counts in cognitive-behavioral therapy. Cogn Behav Ther, 2013. 42 (3): p. 171-9. Kazantzis, N., Whittington, C., & Dattilio, F., Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 2010. 17 (2): p. 144. Kendzerska, T., et al., The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review. Risk Manag Healthc Policy, 2021. 14 : p. 575-584. Parkinson, A., et al., The impact of COVID-19 on chronic disease management in primary care: lessons for Australia from the international experience. Med J Aust, 2022. 216 (9): p. 445-448. Melman, G.J., A.K. Parlikad, and E.A.B. Cameron, Balancing scarce hospital resources during the COVID-19 pandemic using discrete-event simulation. Health Care Manag Sci, 2021. 24 (2): p. 356-374. Davis, B., B.K. Bankhead-Kendall, and R.P. Dumas, A review of COVID-19's impact on modern medical systems from a health organization management perspective. Health Technol (Berl), 2022. 12 (4): p. 815-824. Boldrini, T., et al., Psychotherapy During COVID-19: How the Clinical Practice of Italian Psychotherapists Changed During the Pandemic. Front Psychol, 2020. 11 : p. 591170. Matthias, M.S., et al., The patient-provider relationship in chronic pain care: providers' perspectives. Pain Med, 2010. 11 (11): p. 1688-97. Kroenke, K., Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management. Int J Methods Psychiatr Res, 2003. 12 (1): p. 34-43. Additional Declarations No competing interests reported. Supplementary Files SupplementalMaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 12 Mar, 2024 Reviewers agreed at journal 01 Feb, 2024 Reviews received at journal 08 Jan, 2024 Reviewers agreed at journal 04 Jan, 2024 Reviewers invited by journal 04 Jan, 2024 Editor invited by journal 02 Jan, 2024 Editor assigned by journal 02 Jan, 2024 Submission checks completed at journal 02 Jan, 2024 First submitted to journal 20 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3783148","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264824718,"identity":"b83abfa6-a7af-475c-9b90-360fc507e9c4","order_by":0,"name":"Alan McGuire","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYDACdhiDGYg/EKWFGYnBOIM0LSA2DzE6+JuZnz1gzLGz23Cc9+Fj2zY7Bnn3HgO8WiQOs5kbMG5LTt5wmN3YOLctmcHwzBn8WhgOM5hJMG47kGxwmI1NOucMM4PhjLQEvDrkD7N/g2lh/21xpp6wFoPDPGBb7EC2MDNUHGaQl0g+gFeL4WGeMonEbckJkofZmCV7Ko7zGPAcxq9F7nj7NomP2+zs+c4fY/zww6BaTr69sQGvFjAAuj0RpozHAL8dCGAPZ8kTYccoGAWjYBSMLAAARE4+BmiMrKEAAAAASUVORK5CYII=","orcid":"","institution":"United States Department of Veterans Affairs","correspondingAuthor":true,"prefix":"","firstName":"Alan","middleName":"","lastName":"McGuire","suffix":""},{"id":264824719,"identity":"9cc07f0b-eda5-4e67-9e77-fa2eb291ee96","order_by":1,"name":"Mindy Flanagan","email":"","orcid":"","institution":"United States Department of Veterans Affairs","correspondingAuthor":false,"prefix":"","firstName":"Mindy","middleName":"","lastName":"Flanagan","suffix":""},{"id":264824720,"identity":"3a57677d-0055-4a36-b62f-976eb54e701b","order_by":2,"name":"Jessica Coffing","email":"","orcid":"","institution":"United States Department of Veterans Affairs","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Coffing","suffix":""},{"id":264824721,"identity":"d0b39332-df61-46db-adff-b76ba39ba114","order_by":3,"name":"Morgan Traylor","email":"","orcid":"","institution":"United States Department of Veterans Affairs","correspondingAuthor":false,"prefix":"","firstName":"Morgan","middleName":"","lastName":"Traylor","suffix":""},{"id":264824722,"identity":"0efed604-b368-4cdf-88ed-bd880d7c7917","order_by":4,"name":"Laura Myers","email":"","orcid":"","institution":"United States Department of Veterans 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Affairs","correspondingAuthor":false,"prefix":"","firstName":"Marina","middleName":"","lastName":"Kukla","suffix":""},{"id":264824726,"identity":"6f8b841c-cbf9-47ed-8996-6c45bb41db6c","order_by":8,"name":"Marianne Matthias","email":"","orcid":"","institution":"United States Department of Veterans Affairs","correspondingAuthor":false,"prefix":"","firstName":"Marianne","middleName":"","lastName":"Matthias","suffix":""}],"badges":[],"createdAt":"2023-12-20 17:59:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3783148/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3783148/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49113013,"identity":"ebd43235-3f6d-48f7-ac8a-f1a4de211822","added_by":"auto","created_at":"2024-01-03 09:40:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":157069,"visible":true,"origin":"","legend":"\u003cp\u003ePredicted and Actual total number of CBT-CP sessions by month\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3783148/v1/2e8b9dd99753d34d90c66022.png"},{"id":49113011,"identity":"5acc8546-c3c5-4021-a55e-a6876f0f140e","added_by":"auto","created_at":"2024-01-03 09:40:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":115398,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of therapists delivering care and number delivering CBT-CP by month\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3783148/v1/bf8a01bfdc135ad966288eae.png"},{"id":49113345,"identity":"2d87ed22-b060-4119-a2f5-97db7128f3ad","added_by":"auto","created_at":"2024-01-03 09:48:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":154706,"visible":true,"origin":"","legend":"\u003cp\u003ePredicted and Actual total number of psychotherapy sessions by month\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3783148/v1/83f61dc283b01f82db9f06d8.png"},{"id":49113344,"identity":"fe6dd5ee-ad93-4bf0-84e2-340bb3a8eb26","added_by":"auto","created_at":"2024-01-03 09:48:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":100757,"visible":true,"origin":"","legend":"\u003cp\u003ePathways of ISF factors\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-3783148/v1/a46bffd2506b8d37ca409f67.png"},{"id":49113479,"identity":"78a4c64e-7e96-4233-b820-a57cff12e277","added_by":"auto","created_at":"2024-01-03 09:56:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":644097,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3783148/v1/da1e479e-90f1-48ea-8af1-b2314ec29aed.pdf"},{"id":49113015,"identity":"d1770ad3-6f00-426b-ae50-4e16c937a08d","added_by":"auto","created_at":"2024-01-03 09:40:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18450,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-3783148/v1/cb9a7224118e1ae571fef384.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disruption and sustainment of cognitive behavioral therapy for chronic pain in the Veterans Health Administration following the onset of the COVID-19 pandemic","fulltext":[{"header":"Public Significance Statement","content":"\u003cp\u003eThis study examined the disruption of cognitive behavioral therapy for chronic pain- an evidence-based psychotherapy for chronic pain- based on the COVID-19 pandemic. Results point to the importance of supporting healthcare systems in sustaining evidence-based practices in the face of disruptions.\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eSustainability of EBPs (evidence-based practices), or the “continued use of program components…” is “one of the most significant translational research problems”\u0026nbsp;[1]. While substantial research has focused on the barriers and facilitators of initial implementation of EBPs, research on long-term sustainment has lagged behind\u0026nbsp;[2]. Sustainment is of particular importance to healthcare systems and stakeholders as substantial investment in EBP implementation is more easily justified by long-term use and benefits. Emerging research\u0026nbsp;[1-3]\u0026nbsp;indicates that sustainability involves complex interactions between contextual factors (e.g., factors related to the healthcare system) and the EBP itself, often including adaptations to the EBP over time. Despite important theoretical work regarding sustainability, empirical examinations of the effects of changing contextual factors on EBP sustainability are lacking.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic represented a major disruption to healthcare systems in which EBPs are provided as well as rapid adaptations in response to changing conditions. Data has indicated healthcare disruptions were substantial and widespread, particularly for non-emergent services and care for chronic conditions\u0026nbsp;[4].Whereas data on overall service provision has painted a clear picture of decreased service quantity and threats to quality, both immediately following the pandemic onset and in the ensuing months, more focused examinations on the sustainment of EBPs, including changes to reach (amount of EBP sessions offered) and how EBPs have been adapted to accommodate the changing healthcare setting, are crucial to understanding both EBP sustainability and the impact of COVID-19 on the quality of available services for patients. Importantly, while the disruptions associated with the COVID-19 pandemic may be exceptional in scope, they may provide valuable insights into the effects of more common healthcare system disruptions such as infrastructural changes, natural disasters, and smaller-scale public health emergencies. It is unclear how EBPs may fare relative to services in general in the face of such disruptions. On one hand, healthcare systems and providers may focus limited resources on practices known to work (i.e., EBPs). On the other hand, EBPs may provide particular barriers to sustainment in the context of service disruption.\u003c/p\u003e\n\u003cp\u003eOne predominant adaptation is the conversion to telehealth. For instance, the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States, issued a policy in March of 2020 calling for the maximization of telehealth to minimize community spread of COVID-19\u0026nbsp;[5]. Consequently, telehealth increased from 14% of total visits pre-pandemic to 58% in June of 2020\u0026nbsp;[4]. Research has supported the effectiveness of telehealth provision of EBPs\u0026nbsp;[6, 7]; however, this research has focused on EBPs built for or carefully adapted to telehealth. Little is known about the rapid adaptation of EBPs to telehealth in response to a public health emergency.\u003c/p\u003e\n\u003cp\u003eThe current study focuses on one EBP- cognitive-behavioral therapy for chronic pain (CBT-CP). CBT-CP is a core EBP for the management of a range of chronic pain conditions and is considered the centerpiece of multidisciplinary pain management programs\u0026nbsp;[8]. Numerous randomized controlled trials have supported CBT-CP’s salubrious effects on pain interference and pain catastrophizing\u0026nbsp;[9-11]. For these reasons, CBT-CP is included in numerous guidelines for chronic musculoskeletal pain conditions and has been implemented system-wide in the VHA), the largest integrated healthcare system in the United States. In 2012, VHA initiated implementation of CBT-CP through its national implementing EBPs program\u0026nbsp;[12]. The program includes rigorous training for therapists followed by case-led consultation. Early data indicated widespread training and implementation of CBT-CP with high fidelity to the model. The sustainment of CBT-CP during the COVID-19 pandemic is of particular importance given known disproportionate burden on people with chronic conditions, structural barriers to providing other evidence-based chronic pain treatments via telehealth (e.g., acupuncture, spinal manipulation, etc.), and the risks associated with increased opioid prescribing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current study examined the change in CBT-CP reach (defined as both total number of CBT-CP sessions and percentage of therapy sessions classified as CBT-CP) and adoption (number of therapists providing CBT-CP) following the issuance of VHA’s COVID-19 policy. Total psychotherapeutic services provided by CBT-CP were also modeled as a reference. Additionally, the experiences of CBT-CP therapists adapting CBT-CP for widespread virtual provision as a result of these changes was explored. Taken together, results elucidate both the impact on an EBP’s sustainment in the face of rapidly changing contexts as well as mechanisms by which contextual changes are perceived to affect sustainment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eSample\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuantitative Sample:\u0026nbsp;\u003c/em\u003eThe study sample included therapists who completed the VHA official CBT-CP training and consultation process (n = 478). The sample was limited to those who delivered at least one CBT-CP session between 02/01/19 and 03/31/21 (n = 414; 86.6%). Additionally, because analyses focused on comparing CBT-CP delivery before and after the COVID-19 onset, the sample was further limited to therapists that had at least one appointment during February 2019 – February 2020 and March 2020 – March 2021, respectively (n = 384; 80.3%). This decision excluded therapists hired after the onset of COVID-19 as well as those that had left at some point prior to the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative sample\u003c/em\u003e: Potential interviewees were identified from the therapists described above who completed VHA training and provided at least one session of CBT-CP in the previous year. The sample was further limited to providers who had on average of at least four appointments a month (n=59). Finally, in accordance with VHA policy, the sample was limited to those whose medical center leadership responded to our request to contact providers at their facility (n=34).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMeasures and Procedures\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychotherapeutic\u0026nbsp;\u003c/em\u003evisits were identified as visits provided by sample therapists with a procedural code indicating individual or group psychotherapy (see supplement for full list of codes). \u003cem\u003eCBT-CP visits\u0026nbsp;\u003c/em\u003ewere defined as a subset of psychotherapy visits identified using an iterative algorithm developed for this project. The algorithm was revised based on chart-review validation. The final algorithm combines a SQL string search for terms specific to CBT-CP (e.g., “cognitive-behavioral therapy for chronic pain”) with procedural codes commonly associated with CBT-CP sessions (e.g., individual psychotherapy, behavioral health integration, etc.; see Supplemental Material). Chart reviews on a randomly selected subset of available cases (n=103 patients, 100 providers) indicated that the final algorithm demonstrated good sensitivity (72.9%) and excellent specificity (98.9%). \u003cem\u003eClinics\u0026nbsp;\u003c/em\u003ewere identified using VA stop codes, which are administrative codes used to designate clinical functional groups within which services are provided.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne study member (MT) conducted semi-structured interviews with participants. The interview guide focused on the disruption of CBT-CP services due to the COVID-19 pandemic and was based on framework for modifications of EBPs\u0026nbsp;[13]. Interviews were conducted via video, audio recorded, and transcribed for analysis. Their average length was 30 minutes, with a range of 15 to 57 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnalysis\u003c/p\u003e\n\u003cp\u003eQuantitative: Descriptive statistics were calculated for monthly and total number of visits, CBT-CP sessions, percent of visits in specific clinics (PTSD, Mental Health, Substance Use Disorder, Biomedical, Integrative Care, Pain Specialty) and telehealth visits. These calculations were made per therapist and per month. Time since CBT training was calculated as March 1, 2020, minus date of CBT training and included in descriptive statistics. Wilcoxon signed rank test was used to establish whether therapists’ percentages of CBT-CP visits differed between February 2019 – February 2020 and March 2020 – March 2021. McNemar’s Test was conducted to compare proportion of therapists delivering CBT-CP pre- and post-pandemic.\u003c/p\u003e\n\u003cp\u003eA single group interrupted time series was conducted to understand the impact of the COVID-19 pandemic on CBT-CP delivery; an identical model was run for total psychotherapy (minus CBT-CP visits) for reference purposes. Models were estimated using a repeated measures Generalized Estimating Equations approach with a negative binomial distribution appropriate to count data and a first-order autoregressive correlation structure. The model contained \u003cem\u003etime\u003c/em\u003e (coded as a continuous variable starting at -13 for first month, 0 for March 2020, and 12 for last month), \u003cem\u003einterruption\u003c/em\u003e (coded as 0 for pre-pandemic, 1 for March 2020 and after), and \u003cem\u003etime since interruption\u003c/em\u003e (coded as a continuous variable, 0 for pre-pandemic and March 2020, 1 to 12 for months following). The following equation represents the time series model:\u003c/p\u003e\n\u003cp\u003eNumber of sessions = β0 + β1 * \u003cem\u003etime\u003c/em\u003e + β2 * \u003cem\u003einterruption\u003c/em\u003e + β3 * \u003cem\u003etime since interruption\u003c/em\u003e + e\u003c/p\u003e\n\u003cp\u003eHere, number of CBT sessions per month is the outcome; β0 represents the predicted number of CBT sessions prior to the interruption; β1 is the slope for number of CBT sessions prior to the interruption; β2 is the amount of change in number of CBT sessions immediately after the interruption; β3 is the change in slope for number of CBT sessions after the interruption. The output for this paper was generated using SAS software 9.4. Copyright © 2013 SAS Institute Inc. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative:\u003c/em\u003e Two experienced data analysts (AM, MT) conducted qualitative data analysis. Toward this end, the first grounded themselves in the data by reading full transcripts of interviews and recording memos on emergent themes and lessons learned. These memos facilitated creation of a codebook. As analysts continued to read transcripts, codes were combined, added, and deleted until the codebook was stable and consistent and both coders reached consensus. Both coders independently coded transcripts and results were compared, discrepancies were resolved and modifications to themes made. Once the codes/themes reached stability, one coder coded half the remaining interviews and the other coder reviewed results. Summaries were entered into matrices. Matrices were analyzed to understand within and across therapist themes. Themes were summarized and triangulated by comparison to original data. Data were managed in Microsoft Excel.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudy procedures were approved by the Indiana University IRB and Richard L Roudebush VAMC Research and Development Committee.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eQUANTITATIVE RESULTS\u003c/p\u003e\n\u003cp\u003eSample\u003c/p\u003e\n\u003cp\u003eThree hundred eighty-four CBT-CP trained therapists met inclusion criteria. Included therapists were predominately psychologists and averaged about four years since their CBT-CP training (Table 1). Therapists provided the plurality of CBT-CP session in general Mental Health Clinics, about a fifth in Integrative Care (mental health integrated within medical care clinics such as primary care), and less than 10% each for PTSD, Substance Use Disorder, Biomedical, or Pain Specialty clinics. For this observation period, therapists delivered a median of 1375 therapeutic sessions (IQR=933, 2001). The median number of CBT-CP sessions delivered per therapist was 48.5 (IQR=12.5, 138) during the period of interest. Of total sessions per therapist, the median rate of CBT-CP sessions delivered was 4.3% (IQR=1.1, 10.9) and ranged from 1% to 89%. Across all months, CBT-CP was delivered in 8.0% of all sessions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePandemic Disruption\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll indicators pointed to disruption of CBT-CP delivery at the pandemic’s onset. Interrupted time-series analyses showed pre-pandemic month-to-month change in CBT-CP sessions was not different from zero (Table 2); however, at the time of the interruption in March 2020, the change in CBT-CP sessions was estimated as a 29.7% reduction from the previous month. Moreover, post-interruption growth was not significantly different from zero. Figure 1 displays predicted and actual total number of CBT-CP sessions by month across all providers. Additionally, the percentage of psychotherapy sessions identified as CBT-CP dropped from 9.4% of all psychotherapies pre-interruption to 8.2% following the pandemic onset (S = -6333, p = .004). Finally, the percentage of therapists providing any CBT-CP dropped from 94.3% (362/384) pre-pandemic to 88.3% (339/384) after onset (\u003cem\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e(1) =7.90, p=.005; Figure 2).\u003c/p\u003e\n\u003cp\u003eTotal psychotherapy (excluding CBT-CP visits) demonstrated similar, albeit less severe, disruption. As shown in Table 3, prior to the COVID-19 pandemic, the rate of psychotherapy services was not changing month-to-month. At the time of the interruption in March 2020, the change in psychotherapy sessions was estimated as a 26.9% reduction from the previous month. After disruption, the rate of psychotherapy sessions was positive; for example, a 1% increase was estimated for April 2020 to May 2020. Figure 3 displays predicted and actual total number of sessions by month across all providers.\u003c/p\u003e\n\u003cp\u003eQUALITATIVE RESULTS\u003c/p\u003e\n\u003cp\u003eSample\u003c/p\u003e\n\u003cp\u003eOf the 34 providers contacted, 12 declined:1 due to being in a supervisory role and not providing CBT-CP and 11 due to lack of time. 11 providers did not respond to interview requests. The final sample consisted of 11 providers who completed interviews.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eDuring interviews, CBT-CP therapists described their experiences of delivering CBT-CP after the onset of COVID-19. Generally, such sustainment involved transitioning to video sessions. During this transition, therapists described several challenges to video delivery of CBT-CP.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConcerns Regarding Engagement in Sessions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile therapists generally thought virtual sessions increased access, they had concerns with patients’ engagement in sessions. One therapist noted, \u003cem\u003e“The challenges that I saw, especially with [CBT-CP delivered in a] group, was having them actively participate and feel like there was this sense of accountability where they didn't need to turn off their camera\u003c/em\u003e.” \u003cem\u003e(Participant 11)\u003c/em\u003e Another therapist doubted the engagement with group curriculum, stating:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I don't know how much they were using the handouts and the materials. I don't know how much they were following through on homework when we would do our check-in at the beginning of the next appointment. I generally did not get a lot of feedback even with direct questions about ‘Did you work on this? How did it go?’... I did not find that the protocol was as effective as far as consistency of people attending and the follow-through on actually doing the homework.” (Participant 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral therapists expressed concerns about group cohesion, e.g\u003cem\u003e., “I would say as a clinician though… having patients in a group in a room [is better] because that group dynamic really becomes part of the treatment itself.”\u003c/em\u003e And therapists feared virtual care inhibited natural dynamics and connection among group members:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think it became more psychoeducational. And I did feel like there was less interaction, especially if somebody would turn their camera off…I think that the engagement was more difficult… Yeah. It felt like it was a little more formal, you know. Typically, when I have in person groups there's a lot of joking and sometimes seeing veterans hang around after the group is over and… exchanging phone numbers. So, that went down a lot. I don't know if any of them made connections with each other through that. (Participant 8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGiven these concerns, several therapists developed strategies to support group cohesion in the virtual environment. One therapist learned to utilize the virtual platform to facilitate participation: \u003cem\u003e“And these kind of muting things, we figured out, and how to utilize the chat in groups to encourage participation with the group members, to allow for more sharing.”\u003c/em\u003e (Participant 6) Another therapist intentionally made space for personal connections between group members:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhat we did is recruit, like if you want to share and chat your phone number, you can. Because typically, they would do that in the lobby before or after group. But we don't have, I don't have a lobby, so, you know, at times, we would just as providers, one of us would just stay on for a few minutes afterwards to allow them to chat or just to type in the chat, kind of the informal kind of like connections, it would make outside of group. We built in a little bit of time before and after group for them to be able to do that. (Participant 6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDisruptions from the Home Environment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConcerns with engagement sometimes emerged due to patients participating in therapy sessions from home. For example, one therapist commented on challenges that arise when patients have children at home during sessions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome of them are just confounding issues that you can't necessarily get rid of like you're at home and you have little kids and your little kids are going to interrupt you no matter how many times we set rules and boundaries. Can I have this? Can I do this? They wanna come play with you. It's very hard to establish that when you're not in clinic in that kind of position. (Participant 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRespondents emphasized other informalities of the home environment that can disrupt care:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I saw my share of shirtless veterans or people, you know, having to tell them you can't do this appointment while you're driving your car, you know, or walking around Walmart. So, you know, that's, I think those were the major issues.” (Participant 8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“But then like I had said before, being able to monitor the noises and manage the things that are going on behind our veterans.” (Participant 11)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast to the above challenges, one respondent noted that the home environment can also be advantageous: \u003cem\u003e“That's even better because the patient is at home, and so, you have that ability to be able to see their environment, to help them with various boundaries, etc. that aren't always as in vivo, you know, when they're coming to see you in the office.” (Participant 9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLogistical Difficulties\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLogistical difficulties often made offering virtual services challenging, in general. Multiple providers spoke about the amount of extra preparation it took to transition to virtual (Participants 2, 3, 5, 6, and 11). Due to moving to a virtual setting the providers were no longer able to give patients the materials for group during their group time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo make sure that patients had the materials, providers either sent the group materials via digital means such as MyHealtheVet (VHA’s patient portal), or they printed the materials and mailed them to the veterans. Participant 6 below describes the time demand it took to get the materials to the veterans at home:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe have to break apart the handout because we have to send it in two emails because there’s a megabyte limit on what we can send on MyHealtheVet, creating time to send packets in the mail, creating time to send off the packets that get printed, and approvals for that because, you know, large print jobs, you can’t just print them at the VA. You have to go and send them out as well, so. I would say like what I remember, and in talking with the psychology resident at that time, was the amount of administrative time demand to move the group to online.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eScreen sharing was an option but proved to be unreliable; one therapist described it like this:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe other concern for that too is that when people join virtual appointments on their phone, even when you share screen, it’s gonna be too small for them to be able to read it. And so that creates an issue with their kind of following along like a, again, a cognitive session in particular for them to be able to follow along in the appointment. (Participant 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eScheduling was another logistical hurdle that providers had to overcome. Providers spoke about themselves as well as their schedulers having trouble managing the multiple software programs and getting patients scheduled for virtual sessions (Participants 1, 2, 3, 5, and 8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo, certainly, there had to be some, you know, adjustment to new grids, and you know, how to kind of navigate your schedule, et cetera, and getting patients scheduled, and you know, making sure patients know that it’s a virtual appointment not an in-person appointment. … And then working with the virtual care manager …Or you know, they might be scheduled in [the electronic health record], but I don’t have a VVC [VA Video Connect] link, or the patients reporting not having a VVC link. And so, I think those may be some of the administrative strains. So, just a little bit more to pay attention to and organize. (Participant 2).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTechnical issues also troubled the providers. To resolve these issues, providers submitted technology consults for the patients, used clinical time to troubleshoot connectivity issues, and switched to a phone call. \u0026nbsp;(Participants 2, 4, and 6).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study shows the notable disruptions in delivery of CBT-CP in VHA in the period following the onset of the COVID-19 pandemic and describes therapists\u0026rsquo; perceptions of the challenges in sustaining CBT-CP after a rapid transition to a virtual format. Results of the interrupted time-series analysis demonstrated that both the number of CBT-CP sessions and CBT-CP sessions as a percentage of total session declined and fewer therapists provided CBT-CP post-pandemic compared to pre-pandemic. Moreover the number of CBT-CP sessions was not growing at a significant rate in the post-onset period. As a reference, total psychotherapy session (excluding CBT-CP sessions) dropped, albeit by a smaller percentage, at the pandemic onset and demonstrated significant positive growth in the post-onset period.\u003c/p\u003e \u003cp\u003eBelow, we conceptualize this disruption as a problem of sustainment and consider it in the context of the Integrated Sustainability Framework (ISF; Shelton et al., 2018). The ISF states sustainment is affected by \u0026ldquo;dynamic interactions among outer contextual factors, inner contextual or organizational factors, processes, intervention characteristics, and implementer characteristics\u0026rdquo; and allows for interactions between any and all factors. We postulate two pathways involving a subset of ISF factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), supported by extant literature regarding the COVID-19 pandemic\u0026rsquo;s effects on healthcare delivery and our findings, that may explain the mechanisms by which the pandemic\u0026rsquo;s onset may have reduced CBT-CP sustainment.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePathway 1\u003c/b\u003e starts with a change in \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003epolicy (outer contextual factor)\u003c/span\u003e, the VHA policy in response to the COVID-19 pandemic mandating maximization of virtual care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and hypothesizes that the policy change led to \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eadaptation (process)\u003c/span\u003e- the conversation of psychotherapy to virtual delivery- which decreased the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eperceived benefit (intervention characteristic)\u003c/span\u003e of CBT-CP, which eroded its \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003esustainability\u003c/span\u003e. Several providers interviewed perceived virtual CBT-CP as less effective (and thus beneficial) than in-person CBT-CP. Therapists noticed a decrease in interactivity in the virtual format, including how engaged patients were in sessions. Additionally, in group sessions, providers noted the lack of interaction among group participants, which undermined the extent to which group cohesion, a contributor to effectiveness, could be established [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, another therapist expressed doubt regarding engagement with homework and worksheets, which has been shown as a moderator of effective CBT interventions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Taken together, there is sufficient reason to suspect the adaptation of CBT-CP to virtual care may have led to decreased perceived benefit of the intervention and subsequently reduced its sustainability.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePathway 2\u003c/b\u003e focuses on the interaction between the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eadaptation process\u003c/span\u003e and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003einner contextual factors\u003c/span\u003e. Substantial literature has documented how the COVID-19 pandemic strained \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eorganizational resources\u003c/span\u003e and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estaffing (inner contextual factors)\u003c/span\u003e [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In addition to the direct effects of the pandemic on these inner context factors, results from our interviews elucidated the strain the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eadaptation\u003c/span\u003e to virtual care placed on organizational resources. Therapist interviews highlighted the increased burden of scheduling processes, acclimate patients to virtual platforms, and manage distribution of materials. In their review of the sustainability literature, [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]) noted factors related to capacity, stability of the workforce, and competing demands were commonly associated with sustainment, thus supporting the relevance of these strains on the sustainability of CBT-CP. However, our interviews did not provide perspectives directly relevant to the mechanisms by which these inner contextual changes eventually led to decreased sustainability of CBT-CP. One reasonable speculation is that, given their overwhelming burden, many CBT-CP therapists chose not to convert CBT-CP to a virtual service and therefore stopped offering it. This hypothesis is supported by the decreased number of therapists providing CBT-CP following the pandemic onset.\u003c/p\u003e \u003cp\u003eBoth pathways above delineate the mechanisms by which the onset of the COVID-19 pandemic led to decreased sustainability of CBT-CP; however, it is unclear the degree to which CBT-CP was uniquely affected in comparison to psychotherapy, in general. While non-CBT-CP services were disrupted, the overall drop was somewhat less severe and services showed a significant post-disruption growth. One previous study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] found therapists with a cognitive-behavioral orientation were disrupted more than psychodynamic therapists during the pandemic. Responding therapists provided little insight into impactful differences between CBT-CP and other psychotherapies. One respondent noted problem-solving was necessary to distribute CBT-CP materials to patients. In contrast to some other therapies, CBT-CP calls for the use of a manual, standardized educational material, and assessments. Some of these requirements may have made its conversion and provision in virtual care more difficult. Especially in such resource strained circumstances, even small additional burdens may have made the difference. Finally, CBT-CP differs from many psychotherapies in its targeted population and condition. While most psychotherapies target mental health conditions, CBT-CP deals with chronic pain. Patients with chronic pain require complex care and more time from the provider [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. It is unclear from these data whether CBT-CP trained therapists shifted resources toward alternate treatments for chronic pain or away from patients with chronic pain altogether.\u003c/p\u003e \u003cp\u003eWhile these analyses provide an important opportunity to examine sustainment during a naturally occurring disruption, results should be viewed in the context of their limitations. The interrupted time-series analyses are based on administrative data processed using an algorithm developed for this project that showed a non-negligible false positive rate. However, this rate did not differ before and after pandemic onset, indicating that while our rate of CBT-CP may be an overestimate, it should not change conclusions regarding disruptions. It should also be noted that the estimated post-disruption growth rate of CBT-CP was the same as non-CBT-CP psychotherapy but was not statistically greater than zero due to sample size, variance, or some combination thereof. Therefore, while the evidence that CBT-CP was disrupted more than other psychotherapies is robust, the conclusion that its post-onset recovery was worse should be viewed with caution. Finally, the qualitative data is limited by a small sample of therapists, all of whom did sustain CBT-CP following the pandemic onset. As with all qualitative data, the intent is not generalization; however, this sample has the additional caveat that the perspectives of therapists not sustaining CBT-CP are not captured.\u003c/p\u003e \u003cp\u003eThese findings provide valuable insights into the disruption of EBP sustainability from the COVID-19 pandemic. Moreover, our analyses suggest specific pathways by which the pandemic may have exerted its effects and grounds these pathways in established implementation science frameworks. Future research should test these hypothesized pathways prospectively and with other contexts and practices. Importantly, while the COVID-19 pandemic is unique in its scope, disruptions to healthcare systems such as reorganizations, staffing disruptions, and transitions such as changes to electronic health records systems are common. Therefore, future work is necessary to insulate EBPs from disruptions to ensure their sustainment in the face of disruptions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTherapist characteristics (n\u0026thinsp;=\u0026thinsp;384)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychologist (yes), n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e271/384, (70.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears since CBT-CP training, mean(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of therapeutic Sessions delivered, median(IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1375 (933, 2001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of CBT-CP sessions delivered, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.5 (12.5, 138)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of total sessions delivered that included CBT-CP, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.3 (12.5, 138)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of total sessions delivered by clinic, mean(SD):\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.2 (38.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrative Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.4 (34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain Specialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.3 (22.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.4 (18.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiomedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5 (19.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance Use Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote: CBT-CP\u0026thinsp;=\u0026thinsp;cognitive behavioral therapy for chronic pain; IQR\u0026thinsp;=\u0026thinsp;interquartile range; SD\u0026thinsp;=\u0026thinsp;standard deviation; PTSD\u0026thinsp;=\u0026thinsp;post-traumatic stress disorder\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary results from Interrupted Time Series analysis predicting number of CBT-CP sessions (n\u0026thinsp;=\u0026thinsp;9984 months)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-5.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime since interruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary results from Interrupted Time Series analysis predicting number of psychotherapy sessions (n\u0026thinsp;=\u0026thinsp;9984 months)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e124.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-13.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime since interruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.0004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate: All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the Indiana University Institutional Review Board. Informed consent was obtained from all subjects prior to participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for Publication: Not Applicable\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials: The United States Department of Veterans Affairs (VA) places legal restrictions on access to veteran\u0026rsquo;s health care data, which includes both identifying data and sensitive patient information. The analytic data sets used for this study are not permitted to leave the VA firewall without a Data Use Agreement. This limitation is consistent with other studies based on VA data. However, VA data are made freely available to researchers behind the VA firewall with an approved VA study protocol. For more information, please visit https://www.virec.research.va.gov or contact the VA Information Resource Center (VIReC) at vog.av@CeRIV.\u003c/p\u003e\n\u003cp\u003eCompeting Interests: The authors have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding: This work was supported by a Department of Veterans Affairs Health Services Research and Development Award to Dr. McGuire (IIR 17-094). The sponsor had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. \u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; Contributions: A.M. led the study and qualitative analyses. M.F., L.M., M.M., and M.K. assisted with project design. M.F., J. Coffing, M.T., L. M., N.H., M.K., and M.M. participated in qualitative analyses. N.H., M.T., and J. Carter provided project management. A.M. and M.F. wrote the main manuscript text. M.F., L.M., and J. Coffing designed and conducted the statistical analysis. M.F. prepared the figures. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not Applicable\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; Information: Not Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShelton, R.C. and M. Lee, \u003cem\u003eSustaining Evidence-Based Interventions and Policies: Recent Innovations and Future Directions in Implementation Science.\u003c/em\u003e Am J Public Health, 2019. \u003cstrong\u003e109\u003c/strong\u003e(S2): p. S132-s134.\u003c/li\u003e\n\u003cli\u003eWiltsey Stirman, S., et al., \u003cem\u003eThe sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.\u003c/em\u003e Implement Sci, 2012. \u003cstrong\u003e7\u003c/strong\u003e: p. 17.\u003c/li\u003e\n\u003cli\u003eGlasgow, R.E., et al., \u003cem\u003eRE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review.\u003c/em\u003e Front Public Health, 2019. \u003cstrong\u003e7\u003c/strong\u003e: p. 64.\u003c/li\u003e\n\u003cli\u003eHeyworth, L., Kirsh, S., Zulman, D., Ferguson, J.M., Kizer, K.W., \u003cem\u003eExpanding access through virtual care: the VA\u0026apos;s early experience with Covid-19.\u003c/em\u003e NEJM Catalyst catalyst innovations in care delivery, 2020. \u003cstrong\u003e1\u003c/strong\u003e(4).\u003c/li\u003e\n\u003cli\u003eAdministration, V.H., \u003cem\u003eCOVID-19 Response Plan: Incident-Specific Annex to the VHA High Consequence Infection (HCI) Base plan\u003c/em\u003e. 2020: Affairs DoV, ed. Washington, DC.\u003c/li\u003e\n\u003cli\u003eShigekawa, E., et al., \u003cem\u003eThe Current State Of Telehealth Evidence: A Rapid Review.\u003c/em\u003e Health Aff (Millwood), 2018. \u003cstrong\u003e37\u003c/strong\u003e(12): p. 1975-1982.\u003c/li\u003e\n\u003cli\u003eGros, D.F., Morland, L.A., Greene, C.J., Acierno, R., Strachan, M., Egede, L.E., Tuerk, P.W., Myrick, H. and Frueh, B.C.,, \u003cem\u003eDelivery of evidence-based psychotherapy via video telehealth.\u003c/em\u003e Journal of Psychopathology and Behavioral Assessment, 2013(35): p. 506-521.\u003c/li\u003e\n\u003cli\u003eGatchel, R.J., et al., \u003cem\u003eInterdisciplinary chronic pain management: past, present, and future.\u003c/em\u003e Am Psychol, 2014. \u003cstrong\u003e69\u003c/strong\u003e(2): p. 119-30.\u003c/li\u003e\n\u003cli\u003eMcGuire, A., et al., \u003cem\u003eA National Survey of Patient Completion of Cognitive Behavioral Therapy for Chronic Pain: The Role of Therapist Characteristics, Attempt Rates, and Modification.\u003c/em\u003e Prof Psychol Res Pr, 2021. \u003cstrong\u003e52\u003c/strong\u003e(6): p. 542-550.\u003c/li\u003e\n\u003cli\u003eEhde, D.M., T.M. Dillworth, and J.A. Turner, \u003cem\u003eCognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research.\u003c/em\u003e Am Psychol, 2014. \u003cstrong\u003e69\u003c/strong\u003e(2): p. 153-66.\u003c/li\u003e\n\u003cli\u003eMurphy, J.L., M.J. Cordova, and E.A. Dedert, \u003cem\u003eCognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program.\u003c/em\u003e Psychol Serv, 2022. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 95-102.\u003c/li\u003e\n\u003cli\u003eStewart, M.O., et al., \u003cem\u003eNational dissemination of cognitive-behavioral therapy for chronic pain in veterans: therapist and patient-level outcomes.\u003c/em\u003e Clin J Pain, 2015. \u003cstrong\u003e31\u003c/strong\u003e(8): p. 722-9.\u003c/li\u003e\n\u003cli\u003eMiller, C.J., et al., \u003cem\u003eThe FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare.\u003c/em\u003e Implement Sci, 2021. \u003cstrong\u003e16\u003c/strong\u003e(1): p. 36.\u003c/li\u003e\n\u003cli\u003eBurlingame, G.M., D.T. McClendon, and C. Yang, \u003cem\u003eCohesion in group therapy: A meta-analysis.\u003c/em\u003e Psychotherapy (Chic), 2018. \u003cstrong\u003e55\u003c/strong\u003e(4): p. 384-398.\u003c/li\u003e\n\u003cli\u003eLebeau, R.T., et al., \u003cem\u003eHomework compliance counts in cognitive-behavioral therapy.\u003c/em\u003e Cogn Behav Ther, 2013. \u003cstrong\u003e42\u003c/strong\u003e(3): p. 171-9.\u003c/li\u003e\n\u003cli\u003eKazantzis, N., Whittington, C., \u0026amp; Dattilio, F.,\u003cem\u003e Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension.\u003c/em\u003e Clinical Psychology: Science and Practice, 2010. \u003cstrong\u003e17\u003c/strong\u003e(2): p. 144.\u003c/li\u003e\n\u003cli\u003eKendzerska, T., et al., \u003cem\u003eThe Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review.\u003c/em\u003e Risk Manag Healthc Policy, 2021. \u003cstrong\u003e14\u003c/strong\u003e: p. 575-584.\u003c/li\u003e\n\u003cli\u003eParkinson, A., et al., \u003cem\u003eThe impact of COVID-19 on chronic disease management in primary care: lessons for Australia from the international experience.\u003c/em\u003e Med J Aust, 2022. \u003cstrong\u003e216\u003c/strong\u003e(9): p. 445-448.\u003c/li\u003e\n\u003cli\u003eMelman, G.J., A.K. Parlikad, and E.A.B. Cameron, \u003cem\u003eBalancing scarce hospital resources during the COVID-19 pandemic using discrete-event simulation.\u003c/em\u003e Health Care Manag Sci, 2021. \u003cstrong\u003e24\u003c/strong\u003e(2): p. 356-374.\u003c/li\u003e\n\u003cli\u003eDavis, B., B.K. Bankhead-Kendall, and R.P. Dumas, \u003cem\u003eA review of COVID-19\u0026apos;s impact on modern medical systems from a health organization management perspective.\u003c/em\u003e Health Technol (Berl), 2022. \u003cstrong\u003e12\u003c/strong\u003e(4): p. 815-824.\u003c/li\u003e\n\u003cli\u003eBoldrini, T., et al., \u003cem\u003ePsychotherapy During COVID-19: How the Clinical Practice of Italian Psychotherapists Changed During the Pandemic.\u003c/em\u003e Front Psychol, 2020. \u003cstrong\u003e11\u003c/strong\u003e: p. 591170.\u003c/li\u003e\n\u003cli\u003eMatthias, M.S., et al., \u003cem\u003eThe patient-provider relationship in chronic pain care: providers\u0026apos; perspectives.\u003c/em\u003e Pain Med, 2010. \u003cstrong\u003e11\u003c/strong\u003e(11): p. 1688-97.\u003c/li\u003e\n\u003cli\u003eKroenke, K., \u003cem\u003ePatients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management.\u003c/em\u003e Int J Methods Psychiatr Res, 2003. \u003cstrong\u003e12\u003c/strong\u003e(1): p. 34-43.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cognitive behavioral therapy, nonpharmacological, pain care, chronic pain, veterans","lastPublishedDoi":"10.21203/rs.3.rs-3783148/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3783148/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe sustainability of evidence-based practices (EBPs) is a pressing issue for implementation science and healthcare systems. The COVID-19 pandemic and related policies severely strained healthcare systems, thus representing a key test of the sustainability of EBPs. The current study examined the sustainability of one EBP- cognitive-behavioral therapy for chronic pain (CBT-CP) - in the Veterans Health Administration. Changes in provision of CBT-CP after the onset of COVID-19 were examined both qualitatively, using administrative datasets, and qualitatively, through interviews with CBT-CP providers. Changes in total psychotherapy services were also examined for reference. Results indicated CBT-CP provision was substantially disrupted by COVID-19. Interviewees reported difficulties regarding engagement in virtual sessions, disruptions from the home environment, and logistical challenges. Results indicate specific pathways by which the pandemic may have negatively affected the sustainability of this EBP.\u003c/p\u003e","manuscriptTitle":"Disruption and sustainment of cognitive behavioral therapy for chronic pain in the Veterans Health Administration following the onset of the COVID-19 pandemic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 09:40:47","doi":"10.21203/rs.3.rs-3783148/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-12T04:59:36+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"b78ea4bf-c780-45b0-aff0-1c2c012d5328","date":"2024-02-01T15:46:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-01-08T23:53:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ac084a5b-51fe-4738-ab00-66cabc51a269","date":"2024-01-04T19:04:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-04T15:43:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-01-02T10:43:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-02T07:29:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-02T07:29:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2023-12-20T17:54:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6b5cbc91-f114-406d-9c8d-17bde76a0657","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-08-27T00:37:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 09:40:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3783148","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3783148","identity":"rs-3783148","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}