The patient-provider relationship in chronic pain

The causal impact of shared decision making on pain outcomes: Gender matters

This national US study determined the causal impact of shared decision making (SDM) on pain outcomes, including any overall pain and the subcategories of any acute pain and any chronic pain. We additionally examined whether the causal impact of SDM on overall pain is moderated by gender, race-ethnicity, clinician-patient racial-ethnic concordance, and clinician-patient gender concordance. We used national US data from the 2003-2017 Medical Expenditure Panel Survey, which were externally valid to the US national non-institutionalized population, employed a standard measure of shared decision making, and applied an internally-valid two-stage least squares approach that used the peer SDM behavior of similar clinicians as an instrument. The instrument was sufficiently strong and statistically uncorrelated with patient characteristics. We found a large impact of SDM on both female and male chronic pain outcomes, where the effect for females was approximately 50% larger than for males, with a 10 percentage point increase in SDM quality resulted fewer females experiencing chronic pain that interfered with everyday activities (-24.8 percentage points; 95% confidence interval [CI]: 43.3, -6.4) than males (-16.5 percentage points; 95% CI: 32.9, -1.0). We estimated that a 10 percentage point national increase in the SDM index would thus result in 10.1 million fewer females and 5.7 million fewer males in the US experiencing chronic pain that interfered with their daily activities. Policy implications include both increasing the quality of SDM for all patients and educating male patients on the value of SDM.

Disparities in access but not outcomes: Medicaid versus non-Medicaid patients in multidisciplinary chronic pain rehabilitation

Purpose: There are known disparities in chronic pain severity, treatment, and opioid-related risks amongst individuals from lower socioeconomic status, including Medicaid beneficiaries, but little is known about whether Medicaid beneficiaries benefit in a similar way from multidisciplinary chronic pain rehabilitation. This study investigated differences in clinical outcomes between Medicaid and non-Medicaid beneficiaries who completed a 3-week multidisciplinary chronic pain rehabilitation program.Methods: Participants (N = 131) completed a broad range of clinical measures pre- and post-treatment including pain severity, pain interference, depression, anxiety, objective physical functioning, and opioid misuse risk. Patients with Medicaid were compared with non-Medicaid patients in terms of baseline characteristics and rate of change, utilizing two-factor repeated measures analyses of variance.Results: There were baseline characteristic differences, with Medicaid beneficiaries being more likely to be African American, have higher rates of pain, worse physical functioning, and lower rates of opioid use. Despite baseline differences, both groups demonstrated significantly improved outcomes across all measures (p<.001) and no significant difference in rate of improvement.Conclusions: Results suggest that pain rehabilitation is as effective for Medicaid recipients as non-Medicaid recipients. Patients with Medicaid are particularly vulnerable to disparities in treatment, so efforts to expand access to multidisciplinary pain treatments are warranted.

Borderline personality features are associated with worse perceptions of (but not compliance with) chronic pain treatment

Treating chronic illness requires ongoing patient-provider cooperation, but individual differences in patients' negative perceptions of care can undermine this cooperation. Research suggests people high on borderline personality disorder (BPD) features may react negatively to and comply less with mental health and medical treatment. This might be particularly problematic in chronic pain treatment, where BPD features are over-represented and the dysregulation typifying BPD likely undermines consistent care. In a sample of 147 chronic pain patients, we investigated whether higher levels of BPD features - both in general and by specific facets - predicted worse perceptions of treatment and lower patient-reported compliance with treatment recommendations. Participants higher (vs. lower) on borderline features viewed treatment more negatively but did not report complying less with recommendations. We found evidence that this may reflect the unstable relationships facet of BPD. Our results indicate that, consistent with other treatment settings, BPD features may undermine care for chronic pain. Furthermore, our results highlight the importance of collaborative provider-patient relationships and patient agreement with the treatment of chronic pain, particularly among individuals higher on BPD features.

Communication matters when it comes to adverse events: Associations of adverse events during implant treatment with patients' communication quality and trust assessments

OBJECTIVES

Because patients' trust in their physicians is a critical factor in improving health outcomes and patient response to adverse events, it is important to analyze the determinants of trust. One of these determinants is patient-centered communication. Because the occurrence of adverse events must be communicated to the patient, we asked whether the perceived quality of patient-physician communication acts as an isolating factor between adverse events and patient trust.

METHODS

We proposed and tested a structural equation model linking the occurrence of adverse events to the mediator patient-provider communication quality and to the outcome patient trust. The model was controlled for sociodemographic and health-related factors. We used online survey data from German implant patients (n = 1312), as implant treatment is associated with frequent adverse events such as infections.

RESULTS

Our results show that adverse events during implant treatment are associated with small but significantly lower trust levels. Patient-provider communication quality partially mediates this association.

CONCLUSIONS

Patient trust does not appear to be immune to deterioration from adverse events. Patient-provider communication plays a role in mitigating this association.

PRACTICE IMPLICATIONS

To improve the quality of care, attention should be paid to how adverse events are communicated in a patient-centered manner.

A Qualitative Study on the Experiences of Therapists Delivering the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) Intervention During the COVID-19 Pandemic

BACKGROUND

The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) intervention is a programme of physical activity and exercise designed to maintain participation in activities of daily living, mobility, and quality of life for people living with dementia. During the COVID-19 pandemic first national lockdown in England, the PrAISED physiotherapists, occupational therapists, and rehabilitation support workers adapted to delivering the intervention remotely via telephone or video conferencing.

OBJECTIVE

The aim of this study was to explore therapists' experience of delivering the PrAISED intervention during the COVID-19 pandemic and derive implications for clinical practice.

METHODS

Qualitative semi-structured interviews were conducted with 16 therapists using purposive sampling. Thematic analysis was used to analyze the transcripts.

RESULTS

Therapists reported a change in the relationship between themselves, the person with dementia and the caregiver, with an increased reliance on the caregiver and a loss of autonomy for the person living with dementia. There was concern that this would increase the burden on the caregiver. The therapists reported using creativity to adapt to different modes of delivery. They felt their sessions were mostly focused on providing social and emotional support, and that assessing, progressing, and tailoring the intervention was difficult.

CONCLUSION

It is possible to deliver some elements of a physical intervention using remote delivery, but a dual modal approach including remote and face-to-face delivery would optimize treatment efficacy. Educational support would be required to enable people living with dementia and their caregivers to overcome barriers relating to digital literacy.

“I’m Just Overwhelmed”: Investigating Physical Therapy Accessibility and Technology Interventions for People with Disabilities and/or Chronic Conditions

Many individuals with disabilities and/or chronic conditions (da/cc) experience symptoms that may require intermittent or on-going medical care. However, healthcare is an often-overlooked domain for accessibility work, where access needs associated with temporary and long-term disability must be addressed to increase the utility of physical and digital interactions with healthcare workers and spaces. Our work focuses on a specific domain of healthcare often used by individuals with da/cc: physical therapy (PT). Through a twelve-person interview study, we examined how people’s access to PT for their da/cc  is hampered by social (e.g., physically visiting a PT clinic) and physiological (e.g., chronic pain) barriers, and how technology could improve PT access. In-person PT is often inaccessible to our participants due to lack of transportation and insufficient insurance coverage. As such, many of our participants relied on at-home PT to manage their da/cc  symptoms and work towards PT goals. Participants felt that PT barriers, such as having particularly bad symptoms or feeling short on time, could be addressed with well-designed technology that flexibly adapts to the person’s dynamically changing needs while supporting their PT goals. We introduce core design principles (adaptability, movement tracking, community building) and tensions (insurance) to consider when developing technology to support PT access. Rethinking da/cc  access to PT from a lens that includes social and physiological barriers presents opportunities to integrate accessibility and adaptability into PT technology.

State-Level Sexism and Gender Disparities in Health Care Access and Quality in the United States

In this investigation, we examined the associations between state-level structural sexism-a multidimensional index of gender inequities across economic, political, and cultural domains of the gender system-and health care access and quality among women and men in the United States. We linked administrative data gauging state-level gender gaps in pay, employment, poverty, political representation, and policy protections to individual-level data on health care availability, affordability, and quality from the national Consumer Survey of Health Care Access (2014-2019; N = 24,250). Results show that higher state-level sexism is associated with greater inability to access needed health care and more barriers to affording care for women but not for men. Furthermore, contrary to our hypothesis, women residing in states with higher state-level sexism report better quality of care than women in states with lower levels of sexism. These findings implicate state-level sexism in perpetuating gender disparities in health care.

Evaluation of the functional goal-setting and self-management tool for osteoarthritis, a patient-centred tool to improve osteoarthritis care

OBJECTIVE

Recent American College of Rheumatology guidelines emphasise functional improvement as part of osteoarthritis (OA) management. We developed and evaluated a tool to promote provider and patient engagement in functional goal setting in OA care.

METHODS

We developed the Functional Goal-setting And Self-management Tool (FAST-OA) with clinician input and pilot tested it in two US outpatient clinics. Baseline and end-of-project surveys addressed attitudes toward incorporating function into care and tool evaluation. We analysed survey data descriptively.

RESULTS

Nineteen providers and 49 patients completed surveys. At baseline, both groups endorsed the importance of functional assessment and goal setting. Providers perceived challenges to patients' ability to communicate about function. Both patients and providers highly valued the FAST-OA to promote collaborative discussion and prioritising function. More than half of both groups agreed that they would recommend it to others. End-of-project results suggested changes in provider attitudes toward patients' ability to communicate functional progress. While participants valued the FAST-OA, streamlining content may foster ongoing use.

CONCLUSION

This pilot study illustrates the potential of a function-focused, patient-facing tool to introduce self-management goal-setting strategies into busy clinical workflow, foster the provider-patient relationship, and encourage alignment with guidelines. These results can inform tailoring of tools for use in practice and to address needs of patients and providers optimally.

A qualitative trajectory analysis of patients' experiences tapering opioids for chronic pain

ABSTRACT

Tapering opioids for chronic pain can be challenging for both patients and prescribers, both of whom may be unsure of what to expect in terms of pain, distress, activity interference, and withdrawal symptoms over the first few weeks and months of the taper. To better prepare clinicians to provide patient-centred tapering support, the current research used prospective longitudinal qualitative methods to capture individual-level variation in patients' experience over the first few months of a voluntary physician-guided taper. The research aimed to identify patterns in individuals' experience of tapering and explore whether patient characteristics, readiness to taper, opioid tapering self-efficacy, or psychosocial context were related to tapering trajectory. Twenty-one patients with chronic noncancer pain commencing tapering of long-term opioid therapy were recruited from a metropolitan tertiary pain clinic (n = 13) and a regional primary care practice (n = 8). Semistructured phone interviews were conducted a mean of 8 times per participant over a mean duration of 12 weeks (N = 173). Four opioid-tapering trajectories were identified, which we characterised as thriving, resilient, surviving, and distressed. High and low readiness to taper was a defining characteristic of thriving and distressed trajectories, respectively. Life adversity was a prominent theme of resilient and distressed trajectories, with supportive relationships buffering the effects of adversity for those who followed a resilient trajectory. Discussion focuses on the implications of these findings for the preparation and support of patients with chronic pain who are commencing opioid tapering.

Clinical Correlates of Opioid Prescription Among Pediatric Patients With Chronic Pain

INTRODUCTION

Up to 17%-20% of pediatric patients with chronic pain are prescribed opioid pharmacotherapy and face an increased risk of opioid misuse in adulthood. Little is known about the way clinical presentation may influence which children with chronic pain are prescribed opioids. This study examines the associations between child's and caregiver's report of child's pain, physical function, and socioemotional indices with opioid prescriptions in pediatric patients initiating treatment for chronic pain.

METHODS

Participants were 1,155 pediatric patients (71.26% female, n=823) aged 8-17 years and 1 of their caregivers (89% mothers) who presented for evaluation at a tertiary care pediatric pain clinic. Data were collected from 2015 to 2019 and analyzed in 2020.

RESULTS

Binary logistic regression analyses investigated the relative contribution of child's demographic, pain, and Patient-Reported Outcome Measurement Information System measures to opioid prescription status; separate models were conducted for child's and caregiver's report. Across child and caregiver models, findings were that child's age (older), pain duration (longer; child's report only), and increased physical limitations (mobility challenges and pain interference; caregiver's report only) were the most salient clinical correlates of positive opioid status. Contrary to the existing literature on adults with chronic pain, socioemotional indices (anxiety, depression, peer functioning) were nonsignificant.

CONCLUSIONS

A greater understanding of how clinical presentation may relate to prescribed opioid pharmacotherapy informs the field's conceptualization of the sequelae of opioid use and misuse in the context of pediatric chronic pain.

Improper Communication Makes for Squat: A Qualitative Study of the Health-Care Processes Experienced By Older Adults in a Clinical Trial for Back Pain

BACKGROUND

The study focused on perceptions of older adults toward the healthcare processes they experienced during a clinical trial for back pain that involved family medicine residents and licensed chiropractors.

METHODS

Individual semi-structured interviews were conducted with 115 older adults after a 12-week, 3-arm, randomized controlled trial. Two researchers conducted thematic analysis with inductive coding using qualitative software to identify participants' salient experiences of the doctor-patient relationship, healthcare process, and collaboration between study providers. Investigators categorized thematic codes within an existing framework of clinical excellence in primary care.

RESULTS

Participants emphasized provider communication and interpersonal relationships, professionalism and passion for patient care, clinical and diagnostic acumen, and skillful negotiation of the health-care system. Older adults also described the importance of interdisciplinary collaboration and their preferences for receiving hands-on treatments for musculoskeletal conditions.

CONCLUSION

These older adults valued doctors who communicated clearly and spent time listening to their concerns. Many participants appreciated clinicians who supported an active role for patients in their health-care and who provided touch-based care for musculoskeletal conditions.

Perceived levels of collaboration between cancer patients and their providers during radiation therapy

This study described the patterns within collaborative relationships between patients and health care professionals during radiation therapy (RT). A one-time survey was administered to cancer patients (N=130) receiving RT at one Ontario cancer centre. The key study variables were collaboration between patients and health care providers and participants' well-being. Participants reported higher levels of collaboration with nurses, radiation oncologists, and radiation therapists than with dietitians, social workers and spiritual support personnel [F(5, 760) = 430.42, p < .001]. Participants with more symptom distress collaborated more with some health care professionals than those with less distress, but this was only true for collaboration with social workers (p < .05) and dietitians (p < .05). We postulated that participants did not require services from dietitians and social workers when symptom burden was low. Future directions regarding integration of patient-centred measures (e.g., self-management education) into interprofessional models for cancer care are discussed.

Experiences and attitudes about physical activity and exercise in patients with chronic pain: a qualitative interview study

Purpose

The purpose of this study was to describe how patients with chronic pain experience physical activity and exercise (PA&E).

Method

This qualitative interview study included 16 women and two men suffering from chronic pain and referred to a multimodal pain rehabilitation program. Semi-structured interviews were conducted and qualitative content analysis was used to analyze the interviews.

Results

One main theme emerged: "To overcome obstacles and to seize opportunities to be physically active despite chronic pain." This main theme was abstracted from five themes: "Valuing a life with physical activity," "Physical activity and exercise - before and after pain," "A struggle - difficulties and challenges," "The enabling of physical activity," and "In need of continuous and active support."

Conclusion

Although these participants valued PA&E, they seldom achieved desirable levels, and performance of PA&E was undermined by difficulties and failure. The discrepancy between the intention to perform physical activity and the physical activity accomplished could be related to motivation, self-efficacy, and action control. The participants desired high-quality interaction with healthcare providers. The findings can be applied to chronic pain rehabilitation that uses PA&E as treatment.

Improving satisfaction among established patients in a midwestern pain clinic

BACKGROUND

A problem in many health care practices is deciding the appropriate appointment length for new and established patients. Patients become frustrated when there is inadequate time to have their needs met, yet when a patient's clinic time is spontaneously lengthened, the provider gets behind in schedule, causing delays and greater frustration for others.

AIM

The aims of this evidence based project were to determine whether implementation of a flexible appointment system would improve the current scheduling process in a pain clinic by allowing complex patients the opportunity to schedule a longer clinic appointment and would improve patient satisfaction.

DESIGN

This evidence-based practice innovation followed a program evaluation process using a descriptive, existing survey completed by clinic staff and patients.

SETTING

A Midwestern pain clinic caring for patients with acute and chronic pain diagnoses.

PARTICIPANTS

A convenience sample of 120 patients were surveyed before and after the process change. Thirteen staff members completed the survey on SurveyMonkey pre and post procedural change at the same intervals the patients were surveyed.

RESULTS

Patients were more satisfied with the time that they spent in the exam room and the waiting room. The process change improved communication with staff and patients and provided an opportunity to discuss their concerns and health changes prior to their scheduled appointment.

CONCLUSION

Allowing an option for flexible scheduling in appointment lengths provided an opportunity to meet patient needs, offer improved service, and improve patient-provider communication.

Important role of physicians in addressing psychological aspects of interstitial cystitis/bladder pain syndrome (IC/BPS): a qualitative analysis

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a poorly understood source of chronic pain causing significant morbidity, with variable treatment success. Despite the need to understand patient perspectives in chronic pain, there is a paucity of qualitative data for IC/BPS. We aimed to acquire information regarding patient experience with IC/BPS symptoms and with their medical care to elicit suggestions to improve patient satisfaction with that care.

METHODS

Fifteen women with IC/PBS participated in a total of four focus groups. Sessions were recorded and transcribed and information deidentified. Focus groups were conducted until thematic saturation was reached. All transcripts were coded and analyzed by a minimum of three independent physician reviewers. Investigators identified emergent themes and concepts using grounded-theory methodology.

RESULTS

Participant's mean age was 52.6 years, with an average IC/BPS duration of 6.3 years. Thematic saturation was reached after four focus groups. We identified three emergent patient experience concepts: IC/PBS is debilitating, the disease course is unpredictable and unrelenting, and patients experience significant isolation. Importantly, suicidal ideation was expressed in each group. Patients voiced strong preference for physicians who provided education regarding the condition, an array of treatment options, organized treatment plans, and optimism and hope regarding treatment outcomes.

CONCLUSIONS

Our study presents novel findings of the importance of patient-physician interaction in IC/BPS and reinforces the tremendous disability and burden of this disease, which frequently manifests in suicidal ideation. Patients preferred organized treatment plans with diverse choices and providers who offered hope in dealing with their condition.

You Present like a Drug Addict: Patient and Clinician Perspectives on Trust and Trustworthiness in Chronic Pain Management

OBJECTIVE

Past research has demonstrated that trust is central to an effective therapeutic relationship, but the role of trust in chronic pain management is not well understood. The objective of this study was to provide an in-depth examination of how adults living with chronic pain negotiate trust and demonstrate trustworthiness with clinicians in therapeutic encounters.

METHODS

This qualitative study focused on adults living in an urban setting in British Columbia, Canada. Semi-structured interviews (N = 27) were conducted with participants with chronic low back pain. The results were triangulated by two feedback groups comprising re-contacted interview participants (n = 4) and physicians with expertise in pain and addiction management (n = 6).

RESULTS

Grounded theory analysis of the adult patient interviews and feedback groups yielded four major themes: 1) threats to trustworthiness and iatrogenic suffering; 2) communicating the invisible and subjective condition of chronic pain; 3) motive, honesty, and testimony; and 4) stigmatized identities. The following two themes emerged from the analysis of the physician feedback group: 1) challenges of the practice context, and 2) complicated clinical relationships.

CONCLUSIONS

We found that perceived trustworthiness is important in therapeutic encounters as it helps to negotiate tensions with respect to subjective pain symptoms, addiction, and prescription opioid use. An attitude of epistemic humility may help both clinicians and patients cultivate a trustworthy clinical environment, manage the challenges associated with uncertain testimony, place trust wisely, and promote optimal pain care.

Social pain and physical pain: shared paths to resilience

Although clinical models have traditionally defined pain by its consequences for the behavior and internal states of the sufferer, recent evidence has highlighted the importance of examining pain in the context of the broader social environment. Neuroscience research has highlighted commonalities of neural pathways connecting the experience of physical and social pain, suggesting a substantial overlap between these phenomena. Further, interpersonal ties, support and aspects of the social environment can impair or promote effective adaptation to chronic pain through changes in pain perception, coping and emotional states. The current paper reviews the role of social factors in extant psychological interventions for chronic pain, and discusses how greater attention to these factors may inform future research and clinical care.

Attachment and adjustment in adolescents and young adults with a history of pediatric functional abdominal pain

OBJECTIVES

This study tested predictions of the Attachment-Diathesis Model (ADM) of Chronic Pain in a cross-sectional sample of adolescents and young adults with a history of childhood functional abdominal pain (FAP). ADM posits that attachment anxiety is a diathesis for poor adjustment (physical health, mental health, and functioning) in the context of chronic pain and that pain self-efficacy, pain threat appraisal, and passive coping mediate this effect.

METHODS

Participants (N=261) were recruited from a database of consecutive new patients evaluated for abdominal pain at a pediatric gastroenterology clinic. Participants' mean age at the follow-up assessment was 21 years. Structural equation modeling was used to test the fit of our conceptual model to the data.

RESULTS

Model fit was good (comparative fit index=0.971, the Tucker-Lewis index=0.940, root mean square error of approximation=0.067). Attachment anxiety significantly predicted poorer health in both the mental and physical domains. Model fit was consistent with our hypothesis that pain self-efficacy mediates the effect of attachment anxiety on passive coping and that passive coping, in turn, mediates the effect of pain self-efficacy and pain threat appraisal on mental and physical health.

DISCUSSION

Among individuals with a childhood history of FAP, those with anxious attachment may be at higher risk for poor physical and mental health. Pain beliefs and coping may mediate the relation between anxious attachment and health outcomes and may serve as effective targets for intervention in chronic pain.

Adherence to antiretroviral drug therapy in adult patients who are HIV-positive in Northwest Ethiopia: a study protocol

INTRODUCTION

Achievement of optimal medication adherence and management of antiretroviral toxicity pose great challenges among Ethiopian patients with HIV/AIDS. There is currently a lack of long-term follow-up studies that identify the barriers to, and facilitators of, adherence to antiretroviral therapy (ART) in the Ethiopian setting. Therefore, we aim to investigate the level of adherence to ART and a wide range of potential influencing factors, including adverse drug reactions occurring with ART.

METHODS AND ANALYSIS

We are conducting a 1-year prospective cohort study involving adult patients with HIV/AIDS starting on ART between December 2012 and March 2013. Data are being collected on patients' appointment dates in the ART clinics. Adherence to ART is being measured using pill count, medication possession ratio and patient's self-report. The primary outcome of the study will be the proportion of patients who are adherent to their ART regimen at 3, 6 and 12 months using pill count. Taking 95% or more of the dispensed ART regimen using pill count at given points of time will be considered the optimal level of adherence in this study. Data will be analysed using descriptive and inferential statistical procedures.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Tasmania Health and Medical Human Research Ethics Committee and Bahir-Dar University's Ethics Committee. The results of the study will be reported in peer-reviewed scientific journals, conferences and seminar presentations.

Personal experience of osteoarthritis and pain questionnaires: mapping items to themes

PURPOSE

The aim of this study was to examine the correspondence between qualitative and quantitative methods of coding experience of pain reported by participants with osteoarthritis (OA) of the knee.

METHODS

A mapping grid was produced to record the correspondence between subthemes that emerged from thematic analysis of interviews with 24 participants with knee OA, and from questionnaire items which were used in a study of 192 knee OA participants. Items were rated according to their degree of correspondence between subthemes and questionnaire items, and an overall correspondence score was produced for each subtheme and questionnaire measure.

RESULTS

The subthemes that corresponded well with the questionnaire items were those that related to socio-emotional functioning, the overall experience of pain and the impact of pain on physical functioning. The questionnaire items did not relate to participants' knowledge about their condition and their experience of the medical system.

CONCLUSIONS

The study indicated that many aspects of pain experience reported by patients in qualitative interviews are also assessed by commonly used questionnaire outcome measures for people with pain. However, although participants reported that knowledge about their condition and their experience of the medical system were important aspects of the overall pain experience, these are rarely used as outcome measures. Questionnaires that address these additional aspects of the pain experience could be useful to further evaluate the experience of pain and may help to address important concerns raised by patients with OA of the knee.