Panel-based pain management in primary care. a pilot study

Although pain is an extremely common symptom presenting to primary care physicians, it frequently is not optimally managed. The purpose of this feasibility study was to develop and pilot-test an efficient, rapid assessment and management approach for pain in busy community practices. The intervention utilized the Dartmouth COOP Clinical Improvement System (DCCIS) and a telephone-based, nurse-educator intervention. Patients from four primary care practices in rural New Hampshire and Vermont were screened by mail for the presence of persistent pain. Patients with mild to severe pain were randomized to either the usual care control group (n = 383) or the intervention group (n = 320). Patients who reported pain but no psychosocial problems received a summary of identified problems and targeted educational material via mail (DCCIS). Patients who reported pain and psychosocial problems received the DCCIS intervention and calls from a nurse-educator who provided pain self-management strategies and a problem-solving approach for psychosocial problems. Post-treatment evaluation revealed that patients in the intervention group scored significantly better on the Pain, Physical, Emotional, and Social subscales of the SF-36 and on the total score of the Functional Interference Scale, as compared to a usual care control group. Feasibility and acceptability of the approach were demonstrated; however, the conclusions based on analyses of the post-treatment outcomes were tempered by baseline imbalances across groups.

An observational study of the frequency and pattern of use of epidural steroid injection in 25,479 patients with spinal and radicular pain

BACKGROUND AND OBJECTIVES

Frequency of epidural steroid injections (ESI) and characteristics of patients receiving them are unknown or poorly described. Patients believed to respond better to ESI include young or middle-aged individuals, those with recent onset or a radicular pattern of pain, and patients without previous spinal surgery. The aim of this study is to estimate the frequency of ESI, to examine the characteristics of patients who have them recommended, and to determine if clinical practice reflects published data pertaining to indications for ESI.

METHODS

Descriptive data from 25,479 selected patients with spinal and radicular pain were reviewed. Patients were grouped according to whether or not ESI was recommended, scheduled, prescribed, or continued. Prevalence of ESI use and patient characteristics were compared using standard statistical tests.

RESULTS

Overall, ESI were recommended to 2,022 (7.9%) patients. Patients with lumbar pain had ESI proposed 12.6% of the time. Those with cervical and thoracic symptoms had ESI recommended 3.7% and 1.8% of the time, respectively. Patients in whom ESI was recommended were more likely to have pain radiation (P <.001), dermatomal pain distribution (P <.001), and neurologic signs (P <.001). They also had a greater incidence of comorbidities (P <.001) and were older (P <.001). There was no difference in the frequency of prior surgery (P =.169) nor was there a difference based on gender (P =.548) in patients not recommended to have ESI. Patients with symptom duration between 1 month and 1 year were more likely to have ESI recommended.

CONCLUSIONS

ESI are commonly used to treat patients with spinal and radicular pain. There is some consistency between clinical practice and published recommendations for ESI use.