Painful Facts about Pain Management

Inside Primary Care

Ming Tai-Seale, PhD, MPHTexas A&M Health Science Center

Funding sources: NIMH MH01935, NIA AG15737

2

Co-Authors

Richard Street, Jr., PhD Texas A&M University

Jane Bolin, PhD, JD, RN Texas A&M Health Science Center

Xiaoming Bao, MS Texas A&M Health Science Center

3

Introduction

Chronic pain is common among older adults

PCPs deliver most pain management PCPs serve as “Advanced Medical

Home” for elderly patients Cognitive labor Emotional labor

4

Guideline: Assessment

Assessment and documentation of

Pain location Intensity (scale, happy/sad face…) Onset Duration Variation Rhythms and Manner of expressing

(www.Guidelines.gov)

5

Guideline on Treatment

Develop a written plan of care Pharmacological management Non-pharmacologic strategies

physical activity programs acupuncture patient education, and cognitive behavioral therapy

Follow-up assessments, using same scales and measures

6

Realities in Practice

Time is scarce in primary care Competing demands (Tai-Seale et

al 2006) Pressure to be “productive” and

have short visits Hot-cold empathy gap and under-

treatment of pain (Loewenstein 2003)

Disparities (Bernabei et al. 1998)

7

Current Study Questions

What determines the probability that pain would be discussed?

What happens when pain is discussed?How much time is spent on

addressing pain?What determines the length of time

allocated to pain management?

8

Data

Videotapes 385 patient visits 35 primary care physicians 3 types of practice settings

AMC, MCG, ICS 1999-2000 >2500 topics >100 hours of recording

Patient survey Physician survey

9

Mixed Method Approach

QualitativeWhat happens in a visitWas there a discussion on pain

QuantitativeHow often does pain topic occur How much time is allocated to

discussing pain

10

Sequential Topic Mapping

Pt MD

0.0 0.2

1.1 0.5

7.4 1.6

2.0 0.3

0.9 0.1

11

Patient Sample

Patient Age N (%)

65-75 197 (54)

75-85 132 (36)

>85 37 (10)

Female 243 (65)

White 298 (79)

African American 52 (15)

Other 28 (7)

12

Physician Sample

Age 49 (range: 32-82)

Male 27 (77%)

White 26 (83%)

Academic Med Ctr 10 (29%)

Managed Care Org 21 (60%)

Inner City Solo (AA) 4 (11%)

13

Patient-Physician Dyads

Age matching

14% age ≤10 years of each other

14

Gender Concordance

FemaleMD

MaleMD

Female Pt

18 49

Male Pt 4 29

15

Racial Concordance

White MD

Non-White MD

White PT

79 2

Non-white PT

9 10

16

Visits

# of topics in a visit: Mean = 6.5 Median=6, Min=1, Max=12

Average length of visit 17.4 min

Median length of visit15.7 min

17

Descriptive Statistics

How often 48% at least one discussion of pain

138 contained one pain topic 38 had two pain topics, and 7 had 3 pain topics

How long 3.37 min (6 sec - 15.4 min)

Patient initiation 55%

18

Prob of Having a Pain Topic

O.R. P-value

Different gender 1.64 <.05

SF36 bodily pain .97 <.10

Controlled for: education, MD in family practice, MD years in practice, years of patient-MD relationship, presence of companion, racial concordance, age concordance.

19

Length of Discussion

Duration Analysis H.R. %

2nd – 3rd topic 1.7* -32%

4th – 6th topic 2.2** -44%

≥7th topic 4.7** -68%

≥ high school education 0.7* 25%

Racially discordant 1.5* -24%

Controlled for covariates, *: p<0.05, **: p<0.01

20

Exemplar - Assessment

Stressed out grandma, African American, SF36 pain=25

Older physician, inner city ffs solo,

D: The knees bothering you? Can you expose your knees for me? (examines range of motion) Let's see, does it hurt you in here?

P: No.…

21

Exemplar - Treatment

D: Well let me tell you now, you know how bad your knees are bothering you. Use that as an indicator as to how important it is that you get the weight off them. Understand? Don't want to be falling down, hobbling like this when all you have to do is lose about 50 pounds and you'll move around much better. I'm gonna give you some tablets to take for that, you hear?

…P: What did you think about the Vioxx?

Empathy gap?Emotional, cognitive labor?

23

Conclusions

Sociodemographics and time constraints mattered more than pain

24

Gender concordance was the only factor in determining the probability of having a pain discussion

Length of discussion on pain was determined by time constraints and demographics

Patients with better education had longer discussions about pain

Racial concordance increases the length of discussion, but does not guarantee empathy

Concordance=> better quality?

25

Implications

Standards of care what should happen during the

discussion Primary care as “advanced

medical home” How to make it more functional

System interventions “It’s the System!”

26

Are You Ready?

50 million patients in the U.S. currently enduring chronic pain and

Another 25 million suffering from acute pain

Are you, your colleagues, and employers ready for the WAVE of patients with pain projected to flood the healthcare system when 1 in 5 individuals reach age 65 or older in the year 2011?