Managing pain in high-risk patients within a patient-centered medical home

Insight into chronic pain in the United States: descriptive results from the Prescription Opioid Misuse and Abuse Questionnaire (POMAQ) validation study

OBJECTIVE

A chronic pain patient sample living in the United States who participated in a cross-sectional study to evaluate the validity and reproducibility of the Prescription Opioid Misuse and Abuse Questionnaire is characterized.

METHODS

Patients with chronic pain identified through electronic medical records as refilling at least one opioid prescription within the prior 3 months were recruited from five United States Department of Defense Military Health System clinics. Patients completed the Prescription Opioid Misuse and Abuse Questionnaire, Brief Pain Inventory-Short Form, Medical Outcomes Study: 36-item Short Form, and sociodemographic questions online. Clinical characteristics and electronic medical records for 1 year prior to consent were collected.

RESULTS

809 (86.2%) participants completed the Prescription Opioid Misuse and Abuse Questionnaire. Mean (± standard deviation) age was 55.4 ± 12.7 years; the majority female (55.5%) and white (74.8%). Mean duration of chronic pain was 14.7 ± 10.5 years; the most common pain conditions were lower back pain (76.6%), neck or shoulder pain (60.3%), and osteoarthritis (38.7%). The most commonly prescribed opioids were oxycodone (35.7%), tramadol (34.5%), and hydrocodone (26.9%); 54.8% took one opioid, 44.9% took 2 or more opioids.

DISCUSSION

Participants' health status was poor; pain severity and interference were moderate. Electronic medical record data revealed high healthcare resource utilization. This chronic pain population was severely impacted by their pain condition(s).

Community social determinants and health outcomes drive availability of patient-centered medical homes

The collaborative design of America's patient-centered medical homes places these practices at the forefront of emerging efforts to address longstanding inequities in the quality of primary care experienced among socially and economically marginalized populations. We assessed the geographic distribution of the country's medical homes and assessed whether they are appearing within communities that face greater burdens of disease and social vulnerability. We assessed overlapping spatial clusters of mental and physical health surveys; health behaviors, including alcohol-impaired driving deaths and drug overdose deaths; as well as premature mortality with clusters of medical home saturation and community socioeconomic characteristics. Overlapping spatial clusters were assessed using odds ratios and marginal effects models, producing four different scenarios of resource need and resource availability. All analyses were conducted using county-level data for the contiguous US states. Counties having lower uninsured rates and lower poverty rates were the most consistent indicators of medical home availability. Overall, the analyses indicated that medical homes are more likely to emerge within communities that have more favorable health and socioeconomic conditions to begin with. These findings suggest that intersecting the spatial footprints of medical homes in relation to health and socioeconomic data can provide crucial information for policy makers and payers invested in narrowing the gaps between clinic availability and the communities that experience the brunt of health and social inequalities.

Prospective application of implementation science theories and frameworks to inform use of PROMs in routine clinical care within an integrated pain network

PURPOSE

The objective of this study is to present the implementation science approaches that were used before implementing electronic patient-reported outcome measures (ePROMs) across an integrated chronic pain network that includes primary, rehabilitation, and hospital-based care.

METHODS

The Theoretical Domains Framework (TDF) was used to identify potential barriers and enablers to the use of ePROMS by primary care clinicians. In rehabilitation and tertiary care, the Consolidated Framework for Implementation (CFIR) was used to guide the identification of determinants of implementations, through observation of workflow, patient and clinician surveys, and clinician interviews. A mixed-method concurrent design comprising a quantitative and qualitative analysis was used. The results were reviewed by a steering committee to iteratively inform the ePROM implementation plan. The Proctor framework of evaluation was used to guide the development of an evaluation plan for the implementation of ePROMs in the integrated chronic pain network.

RESULTS

Both frameworks provided similar results with respect to healthcare provider knowledge, behaviour, and experience interpreting PROM scores. The TDF and CFIR frameworks differed in identifying organizational-level determinants. The resultant implementation plan was structured around the adoption of PROMs to inform individual treatment planning and quality improvement. The evaluation plan focused on implementation and impact outcomes to evaluate the ePROM intervention.

CONCLUSIONS

The TDF and CFIR guided the development of a multi-component knowledge translation and training intervention that will address multiple gaps and barriers to implementation of PROMs across the integrated network. The ePROM intervention will aim to increase clinicians' knowledge and skills and foster best practices.

Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) - Protocol for a pragmatic cluster randomized trial

BACKGROUND

Chronic pain is one of the most common, disabling, and expensive public health problems in the United States. Interdisciplinary pain management treatments that employ behavioral approaches have been successful in helping patients with chronic pain reduce symptoms and regain functioning. However, most patients lack access to such treatments. We are conducting a pragmatic clinical trial to test the hypothesis that patients who receive an interdisciplinary biopsychosocial intervention, the Pain Program for Active Coping and Training (PPACT), at their primary care clinic will have a greater reduction in pain impact in the year following than patients receiving usual care.

METHODS/DESIGN

This is an effectiveness-implementation hybrid pragmatic clinical trial in which we randomize clusters of primary care providers and their patients with chronic pain who are on long-term opioid therapy to 1) receive an interdisciplinary behavioral intervention in conjunction with their current health care or 2) continue with current health care services. Our primary outcome is pain impact (a composite of pain intensity and pain-related interference) measured using the PEG, a validated three-item assessment. Secondary outcomes include pain-related disability, patient satisfaction, opioids dispensed and health care utilization. An economic evaluation assesses the resources and costs necessary to deliver the intervention and its cost-effectiveness compared with usual care. A formative evaluation employs mixed methods to understand the context for implementation in the participating health care systems.

DISCUSSION

This trial will inform the feasibility of implementing interdisciplinary behavioral approaches to pain management in the primary care setting, potentially providing a more effective, safer, and more satisfactory alternative to opioid-based chronic pain treatment. Clinical Trials Registration Number: NCT02113592.

Psychometric validation of the electronic chronic pain questions (eCPQ) in a primary care setting

OBJECTIVE

Collecting data that helps evaluate different types of pain may improve physicians' decision-making with regard to treatment selection and on-going monitoring of patients. To date, no chronic pain assessments have been widely implemented in primary care. The aim of this study was to psychometrically validate the electronic Chronic Pain Questions (eCPQ) in a primary care setting.

RESEARCH DESIGN AND METHODS

All men and women ≥18 years arriving at two similar primary care clinics in southeastern Michigan were invited to participate. Clinic staff verbally administered the eCPQ to patients and recorded their answers into the electronic medical record (EMR) prior to physician consultation with results available for physician review. Concurrent validity was assessed using Spearman correlations between eCPQ and patient-completed ancillary measures. Known-group validity was assessed by stratifying patients on self-reported chronic pain as well as by pain diagnosis (i.e. ICD-9 codes). To compare patients with chronic pain versus no chronic pain t-tests and chi-square tests were performed. Reproducibility was assessed between interviewer- and self-administration over time.

RESULTS

A total of 534 patients were invited to participate and 455 patients consented to take part in the study (85.2% response rate); 395 patients had analyzable eCPQ data; 70.1% were Caucasian; 68.1% female; mean age was 43.4; 52.7% (n = 208) self-reported chronic pain. Correlations between eCPQ and ancillary measures supported concurrent validity. Excellent discrimination between groups was evidenced based on self-reported chronic pain and ICD-9 diagnosis. Patients with self-reported chronic pain reported significantly (p < .0001) higher pain ratings and greater interference with usual activities, sleep, and mood than those without chronic pain. Test-retest reliability between modes (interviewer- vs. self-administration) was excellent as was reproducibility based on self-administration of the eCPQ at two separate time points. Key limitations: Discriminant validity was determined by comparing participants based on ICD codes. Utilizing ICD codes to identify individuals with chronic pain may not be a reliable approach as it is dependent upon providers accurately and consistently entering chronic pain diagnoses in the EMR.

CONCLUSIONS

The eCPQ has sound psychometric measurement properties, including concurrent validity, discriminant validity, and reproducibility. The eCPQ appears to be useful to identify patients with chronic pain and to assess and monitor symptoms over time.

Enhancing the Safe and Effective Management of Chronic Pain in Accountable Care Organization Primary Care Practices in Kentucky

Chronic pain is a prevalent chronic condition with significant burden and economic impact in the United States. Chronic pain is particularly abundant in primary care, with an estimated 52% of chronic pain patients obtaining care from primary care physicians (PCPs). However, PCPs often lack adequate training and have limited time and resources to effectively manage chronic pain. Chronic pain management is complex in nature because of high co-occurrence of psychiatric disorders and other medical comorbidities in patients. This article describes a quality improvement initiative conducted by the American College of Physicians (ACP), in collaboration with the Kentucky ACP Chapter, and the Center for Health Services and Outcomes Research at the Johns Hopkins Bloomberg School of Public Health, to enhance chronic pain management in 8 primary care practices participating in Accountable Care Organizations in Kentucky, with a goal of enhancing the screening, diagnosis, and treatment of patients with chronic pain.

Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting

OBJECTIVE

The aim of this study was to compare adherence to opioid prescribing guidelines and potential opioid misuse in patients of resident vs attending physicians.

DESIGN

Retrospective cross-sectional study.

SETTING

Large primary care practice at a safety net hospital in New England.

SUBJECTS

Patients 18-89 years old, with at least one visit to the primary care clinic within the past year and were prescribed long-term opioid treatment for chronic noncancer pain.

METHODS

Data were abstracted from the electronic medical record by a trained data analyst through a clinical data warehouse. The primary outcomes were adherence to any one of two American Pain Society Guidelines: (1) documentation of at least one opioid agreement (contract) ever and (2) any urine drug testing in the past year, and evidence of potential prescription misuse defined as ≥2 early refills. We employed logistic regression analysis to assess whether patients' physician status predicts guideline adherence and/or potential opioid misuse.

RESULTS

Similar proportions of resident and attending patients had a controlled substance agreement (45.1% of resident patients vs. 42.4% of attending patient, P = 0.47) or urine drug testing (58.6% of resident patients vs. 63.6% of attending patients, P = 0.16). Resident patients were more likely to have two or more early refills in the past year relative to attending patients (42.8% vs. 32.5%; P = 0.004). In the adjusted regression analysis, resident patients were more likely to receive early refills (odds ratio 1.82, 95% confidence interval 1.26-2.62) than attending patients.

CONCLUSIONS

With some variability, residents and attending physicians were only partly compliant with national guidelines. Residents were more likely to manage patients with a higher likelihood of opioid misuse.

A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework

Chronic pain affects at least 116 million adults in the USA and exacts a tremendous cost in suffering and lost productivity. While health systems offer specialized pain services, the primary care setting is where most patients seek and receive care for pain. Primary care-based treatment of chronic pain by interdisciplinary teams (including behavioral specialists, nurse case managers, physical therapists, and pharmacists) is one of the most effective approaches for improving outcomes and managing costs. To ensure robust integration of such services into sustainable health-care programs, evaluations must be conducted by researchers well versed in the methodologies of clinical trials, mixed methods and implementation research, bioinformatics, health services, and cost-effectiveness. Recent national health policy changes, in addition to the increasing recognition of the high prevalence and cost of chronic pain conditions, present a unique opportunity to shift the care paradigm for patients with chronic pain.