Chronic Pain Visits Research Articles

Clinician Experiences With Integrative Group Medical Visits for Chronic Pain.

The well-being of healthcare teams is an important consideration when seeking to improve patient experience and quality of care. Prior studies have found that changes to working conditions are most effective in improving clinician well-being. Integrative Group Medical Visits (IGMVs) modify working conditions in ways that have potential to improve clinician experience. The objective of this study was to understand healthcare teams' experiences with IGMVs. In this qualitative study, interviews were conducted via Zoom and telephone with 21 clinicians, administrators, and staff from safety-net healthcare settings throughout the United States (U.S.) who have implemented IGMVs for patients with chronic pain. Interviews included questions about clinician experience, well-being, and satisfaction with the IGMV model. Interviews were recorded, transcribed, and coded using thematic content analysis by a team of trained qualitative researchers. The authors identified five themes describing how IGMV positively affected clinician well-being: organizational supports, human-centered engagement, collaboration with an interprofessional team, provision of guideline-concordant care, and enhanced meaning and purpose for the clinicians. The current study was the first to use interviews from healthcare teams who have implemented IGMV to assess their experience. The themes identified warrant further investigation into IGMVs as a strategy to promote clinician well-being and mitigate aspects of burnout.

Incidence, morbidity, mortality and disparities in dementia: A population linked electronic health records study of 4.3 million individuals.

We report dementia incidence, comorbidities, reasons for health-care visits, mortality, causes of death, and examined dementia patterns by relative deprivation in the UK. A longitudinal cohort analysis of linked electronic health records from 4.3 million people in the UK was conducted to investigate dementia incidence and mortality. Reasons for hospitalization and causes of death were compared in individuals with and without dementia. From 1998 to 2016 we observed 145,319 (3.1%) individuals with incident dementia. Repeated hospitalizations among senior adults for infection, unknown morbidity, and multiple primary care visits for chronic pain were observed prior to dementia diagnosis. Multiple long-term conditions are present in half of the individuals at the time of diagnosis. Individuals living in high deprivation areas had higher dementia incidence and high fatality. There is a considerable disparity of dementia that informs priorities of prevention and provision of patient care.

Experiences of Military Primary Care Providers During Chronic Pain Visits: A Qualitative Descriptive Study.

Chronic pain complaints are the second most common reason for outpatient primary care visits, yet a comprehensive assessment of the processes and experiences of providers during a chronic pain visit is still lacking. This qualitative descriptive study aimed to conceptualize the processes and experiences that military primary care providers go through while they assess and manage chronic pain. Single U.S. Army medical center. Semistructured interviews with 12 military primary care providers. Interviews were audio-recorded, transcribed, and coded with the use of qualitative software. Transcripts were analyzed with thematic analysis to identify emergent themes. Three broad themes with associated subthemes captured the processes and the providers' experiences: 1) comprehending the pain story-asking the right questions about pain impact, navigating through the complexities of the pain story, and conveying understanding of the pain story back to the patient; 2) optimizing the pain story-perceiving provider-patient disconnect on pain management goals, resetting realistic goals, creating an optimal individualized treatment plan, and evaluating treatment effectiveness; and 3) empathetic and therapeutic engagement with patients-trusting patients and fostering the patient-provider relationship. A thematic map illustrates these provider experiences. During chronic pain visits, the provider-patient disconnect on the goals of chronic pain treatment presents a considerable challenge. Further in-depth studies on addressing provider-patient disconnect are warranted to identify solutions, which would help providers communicate realistic chronic pain management expectations to patients. The themes and subthemes described in this study could serve as a guide for directing strategies to improve chronic pain visits in primary care.

Visit Linearity in Primary Care Visits for Patients with Chronic Pain on Long-term Opioid Therapy.

Physicians and patients report frustration after primary care visits for chronic pain. The need to shift between multiple clinical topics to address competing demands during visits may contribute to this frustration. This study creates a novel measure, "visit linearity," to assess visit organization and examines whether visits that require less shifting back and forth between topics are associated with better patient and physician visit experiences. It also explores whether visit linearity differs depending on the following: (1) whether or not pain is a major topic of the visit and (2) whether or not pain is the first topic raised. This study analyzed 41 video-recorded visits using inductive, qualitative analysis informed by conversation analysis. We used linear regression to evaluate associations between visit organization and post-visit measures of participant experience. Patients were established adult patients planning to discuss pain management during routine primary care. Physicians were internal or family medicine residents. Visit linearity, total topics, return topics, topic shifts, time per topic, visit duration, pain main topic, pain first topic, patient experience, and physician difficulty. Visits had a mean of 8.1 total topics (standard deviation (SD)=3.46), 14.5 topic shifts (SD=6.28), and 1.9 topic shifts per topic (SD=0.62). Less linear visits (higher topic shifts to topic ratio) were associated with greater physician visit difficulty (β=7.28, p<0.001) and worse patient experience (β= -0.62, p=0.03). Visit linearity was not significantly impacted by pain as a major or first topic raised. In primary care visits for patients with chronic pain taking opioids, more linear visits were associated with better physician and patient experience. Frequent topic shifts may be disruptive. If confirmed in future research, this finding implies that reducing shifts between topics could help decrease mutual frustration related to discussions about pain.

Qualitative Needs Assessment for the Development of Chronic Pain Group Medical Visits.

Group medical visits (GMVs) for patients with chronic pain are becoming more accessible and have been shown to be successful in furthering patient education on multidisciplinary, nonopioid interventions. Unfortunately, evidence suggests that many group visit models lack sustainability due to recruitment issues and retention rates. Additionally, most of the studies surrounding GMVs are located in primarily urban health centers, potentially limiting their generalizability. This study aims to identify patient interest in and barriers to GMVs for chronic pain and to explore how chronic pain impacts daily lives for GMV content optimization in a nonurban population. Nineteen participants age 18 to 65 years participated in semistructured phone interviews to generate a thematic analysis. Participants received their care from family practitioners at a suburban multiclinic academic medical group and were being prescribed at least 50 morphine milligram equivalents (MME) at the time of recruitment. Analysis generated two themes: (1) Participants expressed specific interest in GMVs with few barriers identified, and (2) Pain has a negative impact on mental health and most aspects daily life, creating a foundation for discussion in GMVs. Findings support significant patient interest in group medical visits for chronic pain, but careful planning is necessary to address patient needs, expectations, and barriers in order to ensure GMV sustainability.

Understanding the Impact of Chronic Pain in the Emergency Department: Prevalence and Characteristics of Patients Visiting the Emergency Department for Chronic Pain at an Urban Academic Health Sciences Centre

ABSTRACT Background Canadians make approximately 16 million visits to the emergency department (ED) each year. ED visits for non-urgent reasons contribute to suboptimal patient care and ineffective resource use. Aims To estimate the proportion of ED visits related to chronic pain at our institution. Methods. We conducted a retrospective review of 1000 randomly selected ED visits at TOH during the 2012–2013 fiscal year (April 1, 2012 to March 31, 2013). Visits for chronic pain were identified using pre-defined criteria. Demographic and medical data were extracted from medical charts. Results 104 visits during this time period were related to chronic pain (10.4%; 95% CI: 8.2–12.6). All visits were from unique patients (i.e., no patients contributed more than 1 visit). Patients were predominantly women (71%), with a mean age of 45.9 years. Seventy-eight percent of patients had a primary care provider. The most common location of pain included the abdomen (24%), the head or face (21%), and the low back (21%). Only 5% of patients had consultation with a pain medicine specialist while 78% were awaiting a consultation. More than 2/3 of patients (71%) reported using opioids for their pain. Conclusion Presenting to the ED for chronic pain was found to occur among a sample of ED visits reviewed. This can result in ineffective care for patients with chronic pain. Cost-effective solutions to improve clinical outcomes and reduce ED use for chronic pain may yield significant improvements in health outcomes of patients and benefits for the health care system.

Reduction of Parenteral Opioid Use in Community Emergency Departments Following Implementation of Treatment Guidelines.

Opioid prescribing guidelines are commonly seen as part of the solution to America's opioid epidemic. However, the effectiveness of specific treatment guidelines on altering opioid prescribing in the emergency department (ED) is unclear. We examined provider ordering patterns before and after implementation of opioid use guidelines for ED patients overall and the specific subsets of ED patients with either chronic opioid use or fracture. We conducted a pre-post interrupted time series analysis of adult (≥18 years old) ED encounters in 14 integrated community EDs before (2013) and after (2014) the implementation of opioid prescribing guidelines. We compared opioid use pre- and postintervention using segmented logistic regression for primary and secondary analyses. The primary outcome was parenteral opioid use in the ED, with additional subgroup analysis of chronic pain and fracture cohorts. We also examined ED oral opioid use and discharge prescribing. There were 508,337 pre- and 531,620 postintervention encounters. The intervention was associated with an initial reduction in the odds of parenteral opioids ordered (odds ratio [OR]=0.89, 95% CI= 0.87-0.91) and a decrease in the monthly trend compared to the preintervention period (OR=0.99, 95% CI= 0.99-0.99). The immediate reduction in parenteral opioid use was significantly larger in the cohort of patients with chronic pain (OR=0.81, 95% CI= 0.72-0.91), whereas the fracture cohort showed no change (OR=1.10, 95% CI= 0.97-1.25). The use of an opioid ordering guideline was associated with significant reduction in parenteral opioid use in the ED and as intended subgroup comparisons suggest that acute fractures were not affected and chronic pain visits were associated with larger decreases in opioid use.

Opioid prescribing by physicians with and without electronic health records.

Physicians in the U.S. are adopting electronic health records (EHRs) at an unprecedented rate. However, little is known about how EHR use relates to physicians' care decisions. Using nationally representative data, we estimated how using practice-based EHRs relates to opioid prescribing in primary care. This study analyzed 33,090 visits to primary care physicians (PCPs) in the 2007-2010 National Ambulatory Medical Care Survey. We used logistic regression to compare opioid prescribing by PCPs with and without EHRs. Thirteen percent of all visits and 33% of visits for chronic noncancer pain resulted in an opioid prescription. Compared to visits without EHRs, visits to physicians with EHRs had 1.38 times the odds of an opioid prescription (95% CI, 1.22-1.56). Among visits for chronic noncancer pain, physicians with EHRs had significantly higher odds of an opioid prescription (adj. OR = 1.39; 95% CI, 1.03-1.88). Chronic pain visits involving electronic clinical notes were also more likely to result in an opioid prescription compared to chronic pain visits without (adj. OR = 1.51; 95% CI, 1.10-2.05). Chronic pain visits involving electronic test ordering were also more likely to result in an opioid prescription compared to chronic pain visits without (adj. OR = 1.31; 95% CI, 1.01-1.71). We found higher levels of opioid prescribing among physicians with EHRs compared to those without. These results highlight the need to better understand how using EHR systems may influence physician prescribing behavior so that EHRs can be designed to reliably guide physicians toward high quality care.

Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain

Introduction Emergency department (ED) overcrowding is a growing problem. Frequent visits for chronic pain are a significant subset of patients. The use of narcotics in these patients is controversial. The purpose of this study was to test a strict nonnarcotic protocol in reducing need for and number of ED visits for chronic pain while at the same time addressing their pain. Methods This was a prospective observational study. We identified patients with more than 10 ED visits for exacerbations of chronic nonmalignant pain in the last 12 calendar months. Each patient and their physician were sent letters informing them of the concern of frequent ED use and the use of opioids for rescue therapy. Furthermore, the patient would receive medications other than narcotics in subsequent ED visits, and follow-up with the primary physician for alternatives was encouraged. Use of the ED for pain-related visits was then monitored for the subsequent 12-month period. Clinic use and outpatient medication uses were also monitored. Results Fifteen patients were identified for the initial study. These patients averaged 19 ED visits per 12 months for pain-related complaints. All of them had a regular physician. After notification of the new protocol, ED visits decreased to an average of 2 visits per year. Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits. There were 7 patients who had been weaned off narcotic medications, 4 who had been converted to methadone maintenance, and 1 who had been switched to a fentanyl patch. Conclusions Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints, and many were weaned off narcotics. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.