Objective Over the past decade, the Department of Veterans Affairs (VA) has experienced a sizeable shift in its approach to pain. The VA’s 2009 Pain Management Directive introduced the Stepped Care Model, which emphasizes an interdisciplinary approach to pain management involving pain referrals and management from primary to specialty care providers. Additionally, the Opioid Safety Initiative and 2017 VA/Department of Defense (DoD) clinical guidelines on opioid prescribing set a new standard for reducing opioid use in the VA. These shifts in pain care have led to new pain management strategies that rely on multidisciplinary teams and nonpharmacologic pain treatments. The goal of this study was to examine how the cultural transformation of pain care has impacted providers, the degree to which VA providers are aware of pain care services at their facilities, and their perceptions of multidisciplinary care and collaboration across VA disciplines. Methods We conducted semistructured phone interviews with 39 VA clinicians in primary care, mental health, pharmacy, and physical therapy/rehabilitation at eight Veterans Integrated Service Network medical centers in New England. Results We identified four major themes concerning interdisciplinary pain management approaches: 1) the culture of VA pain care has changed dramatically, with a greater focus on nonpharmacologic approaches to pain, though many “old school” providers continue to prefer medication options; 2) most facilities in this sample have no clear roadmap about which pain treatment pathway to follow, with many providers unaware of what treatment to recommend when; 3) despite multiple options for pain treatment, VA multidisciplinary teams generally work together to ensure that veterans receive coordinated pain care; and 4) veteran preferences for care may not align with existing pain care pathways. Conclusions The VA has shifted its practices regarding pain management, with a greater emphasis on nonpharmacologic pain options. The proliferation of nonpharmacologic pain management strategies requires stakeholders to know how to choose among alternative treatments.

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Gradual patterns aim at automatically extracting covariations between variables of data sets in the form of "the more/the less" such as "the more experience, the higher salary". This data mining method has been applied more and more in finding knowledge recently. However, gradual patterns are still not applicable on spatial data while such information have strong presence in many application domains. For instance, in our work we consider the issue of potentially avoidable hospitalizations. Their determinants have been studied to improve the quality, efficiency, and equity of health care delivery. Although the statistical methods such as regression method can find the associations between the increased potentially avoidable hospitalizations with its determinants such as lower density of ambulatory care nurses, there is still a challenge to identify how the geographical areas follow or not the tendencies. Therefore, in this paper, we propose to extend gradual patterns to the management of spatial data. Our work is twofold. First we propose a methodology for extracting gradual patterns at several hierarchical levels. In addition, we introduce a methodology for visualizing this knowledge. For this purpose, we rely on spatial maps for allowing decision makers to easily notice how the areas follow or not the gradual patterns. Our work is applied to the measure of the potentially avoidable hospitalizations to prove its interest.