Disease management strategies and the gastroenterologist

Disease management for chronic pain: barriers of program implementation with primary care physicians

OBJECTIVE

This study investigated the implementation of a disease management (DM) program for chronic pain among primary care physicians. Its aim was the dissemination of guidelines for the treatment of chronic pain to help primary care physicians identify, treat, and manage patients highly impaired by pain. The goals of the program were: 1) To identify those pain patients who are at greatest disability due to pain; 2) To assess the impact of a DM program for pain on clinical practice; and 3) To evaluate the effect of the program on physician's use, compliance, and satisfaction with guidelines.

METHODS

Thirty primary care physicians followed 82 patients who were identified as having chronic migraine headaches, back pain, or painful peripheral neuropathy. All patients were categorized according to their level of disability based on ratings of pain intensity, activity interference, emotional distress, perceived support, and work disability. Treatment algorithms developed for this study were placed in the charts of those patients considered to have moderate or high disability. Physicians completed pre- and poststudy questionnaires.

RESULTS

Chronic pain patients could be successfully classified according to the disability from their pain and physicians were open to accepting guidelines for treatment. By the end of the study, primary care physicians reported improved confidence in treating chronic pain. Most felt that chronic pain management was a problem in their practice, and they recognized the benefit of treatment algorithms. Many of the physicians, however, expressed reluctance to regularly consult the algorithms when treating chronic pain.

DISCUSSION

The identification of barriers for implementation of DM programs for pain is presented, and recommendations for future implementation are discussed.

Outcomes research, practice guidelines, and disease management in clinical gastroenterology

The delivery of health care is undergoing dramatic change. Often, patients have come to be viewed as customers and physicians as merely providers. The progressive rise in the cost of medical care has placed a premium on restraint. Unfortunately, quality has not received the same emphasis. As costs equalize among health care systems, however, quality of care will become the major differentiating feature among providers, including gastroenterologists. These changes have lead to what some term the third revolution in medical care, that is, "assessment and accountability". The field of outcomes research has emerged in response to these influences, providing the means to measure the relative effectiveness of different interventions to identify those that provide the most benefit for their cost. At the same time, outcomes research provides a monitoring system to ensure that quality is not sacrificed in the enthusiasm to reduce expenditures. These principles have implications in the practice of clinical gastroenterology.