"It Encourages Them to Complain": A Qualitative Study of the Unintended Consequences of Assessing Patient-Reported Pain

Predictors of 72-h unscheduled return visits with admission in patients presenting to the emergency department with abdominal pain

BACKGROUND

Unscheduled return visits (URVs) to the emergency department (ED) constitute a crucial indicator of patient care quality.

OBJECTIVE

We aimed to analyze the clinical characteristics of patients who visited the ED with abdominal pain and to identify the risk of URVs with admission (URVAs) from URVs without admission (URVNAs).

METHODS

This retrospective study included adult patients who visited the ED of Taipei Medical University Hospital because of abdominal pain and revisited in 72 h over a 5-year period (January 1, 2014, to December 31, 2018). Multivariable logistic regression analysis was employed to identify risk factors for URVAs and receiver operating characteristic (ROC) curve analysis was performed to determine the efficacy of variables predicting URVAs and the optimal cut-off points for the variables. In addition, a classification and regression tree (CART)-based scoring system was used for predicting risk of URVA.

RESULTS

Of 702 eligible patients with URVs related to abdominal pain, 249 had URVAs (35.5%). In multivariable analysis, risk factors for URVAs during the index visit included execution of laboratory tests (yes vs no: adjusted odds ratio [AOR], 4.32; 95% CI 2.99-6.23), older age (≥ 40 vs < 40 years: AOR, 2.10; 95% CI 1.10-1.34), Level 1-2 triage scores (Levels 1-2 vs Levels 3-5: AOR, 2.30; 95% CI 1.26-4.19), and use of ≥ 2 analgesics (≥ 2 vs < 2: AOR, 2.90; 95% CI 1.58-5.30). ROC curve analysis results revealed the combination of these 4 above variables resulted in acceptable performance (area under curve: 0.716). The above 4 variables were used in the CART model to evaluate URVA propensity.

CONCLUSIONS

Elder patients with abdominal pain who needed laboratory workup, had Level 1-2 triage scores, and received ≥ 2 doses of analgesics during their index visits to the ED had higher risk of URVAs.

Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the USA

BACKGROUND

Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low.

OBJECTIVE

This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption.

DESIGN

Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression.

PARTICIPANTS

A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs.

MAIN MEASURES

Health system and physician practice adoption of PROs for depression, pain, and disability.

KEY RESULTS

Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs.

CONCLUSIONS

Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

Pain as the fifth vital sign-A comparison between public and private healthcare systems

Background

The assessment of pain as the fifth vital sign (P5VS) is of paramount importance since it leads to the management of undertreated pain, consequently reducing suffering, readmissions and emergency department visits after hospital discharge.

Objective

To evaluate the implementation of P5VS in public and private hospitals.

Methods

Data analysis on validated questionnaires was sent to all 171 Portuguese hospitals via an official letter.

Results

When compared to private hospitals, public hospitals presented a higher adherence to the process related to the P5VS. It has demonstrated superiority in the charts properly placed to record P5VS, in the number of emergency departments recording P5VS, in the regularity of audits, and in the existence of guidelines and staff training on pain assessment and management.

Conclusion

The standardization of both evaluation and recording of pain intensity constitutes a measure of good clinical practice. Public hospitals demonstrated better commitment to these procedures that should be properly carried out in all health care institutions.

Perceived benefits and limitations of using patient-reported outcome measures in clinical practice with individual patients: a systematic review of qualitative studies

PURPOSE

Patient-reported outcome measures (PROMs) are increasingly used in clinical settings to inform individual patient care. In-depth understanding of end-users' experiences may help identify factors that promote or hinder their use in clinical decision-making. We aimed to examine stakeholder perceptions of the utility of using PROMs in clinical practice based on real-life experience.

METHODS

Systematic review searching Medline, Embase and PsychINFO from inception to May 2021. Qualitative studies examining patients' and/or clinicians' experiences of using PROMs in clinical settings were included. Study screening and data extraction were performed by two independent reviewers. Qualitative data from included studies was analysed thematically.

RESULTS

Of 2388 abstracts retrieved, 52 articles reporting 50 studies met eligibility. Five key benefits were identified: (1) promotes active patient involvement (enables goal setting and discussion of sensitive topics); (2) enhances the focus of consultations (prioritizes patient needs); (3) improves quality of care (enables tailored, holistic care and prompts action); (4) enables standardized monitoring of patient outcomes; and (5) enhances the patient-clinician relationship (provides reassurance). Perceived limitations included the capacity of PROMs to shift the focus of consultations; inaccurately estimate problems; raise unrealistic expectations for care; inhibit patient-clinician interaction; lack clinically meaningful information; and not be suitable for all patients.

CONCLUSION

Both patients and clinicians reported benefits of using PROMs across diverse health conditions and clinical settings, but also highlighted several limitations. These limitations shed some light on why PROM use may not always improve patient outcomes and provide considerations for the design and implementation of future PROM initiatives.

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

OBJECTIVE

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.

SETTING

Single US Army medical center.

METHODS

Semi-structured interviews with 12 military primary care providers. Interviews were audio-recorded, transcribed, and coded using qualitative software. Transcripts were analyzed using thematic analysis to identify emergent themes.

RESULTS

Three broad themes with associated sub-themes captured the processes and providers' experiences: 1) comprehending the pain story - asking the right questions regarding pain impact, navigating through complexities of the pain story, and conveying understanding of pain story back to the patient; 2) optimizing the pain story - perception of provider-patient disconnect on pain management goals, re-setting realistic goals, creating optimal individualized treatment plan, and evaluating treatment effectiveness; and 3) empathetic and therapeutic engagement with patients - trusting patients and fostering patient-provider relationship. A thematic map illustrates these provider experiences.

CONCLUSIONS

During chronic pain visits, the provider-patient disconnect on 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 sub-themes described in this study could serve as a guide for directing strategies to improve chronic pain visits in primary care.

"Asking Is Never Bad, I Would Venture on That": Patients' Perspectives on Routine Pain Screening in VA Primary Care

OBJECTIVE

Screening for pain in routine care is one of the efforts that the Veterans Health Administration has adopted in its national pain management strategy. We aimed to understand patients' perspectives and preferences about the experience of being screened for pain in primary care.

DESIGN

Semistructured interviews captured patient perceptions and preferences of pain screening, assessment, and management.

SUBJECTS

We completed interviews with 36 patients: 29 males and seven females ranging in age from 28 to 94 years from three geographically distinct VA health care systems.

METHODS

We evaluated transcripts using constant comparison and identified emergent themes.

RESULTS

Theme 1: Pain screening can "determine the tone of the examination"; Theme 2: Screening can initiate communication about pain; Theme 3: Screening can facilitate patient recall and reflection; Theme 4: Screening for pain may help identify under-reported psychological pain, mental distress, and suicidality; Theme 5: Patient recommendations about how to improve screening for pain.

CONCLUSION

Our results indicate that patients perceive meaningful, positive impacts of routine pain screening that as yet have not been considered in the literature. Specifically, screening for pain may help capture mental health concerns that may otherwise not emerge.

"Sometimes you wonder, is this really true?": Clinician assessment of patients' subjective experience of pain

BACKGROUND

Pain is a subjective experience that must be translated by clinicians into an objective assessment to guide intervention.

OBJECTIVE

To understand how patients' subjective experience of pain is translated by primary care clinicians into an objective clinical assessment of pain to effectively guide intervention.

METHODS

We conducted nine multidisciplinary focus groups with a combined total of 60 Veteran affair (VA) primary care providers and staff from two large VA medical centers in California and Oregon. We used content analysis methods to identify key themes pertaining to clinical assessment of a subjective experience.

RESULTS

We present four emergent themes. Theme 1: Pain is a highly individualized and subjective experience not adequately captured by a simple numeric scale; Theme 2: Conflict commonly exists between the patient's reported experience of pain and the clinician's observations and expectations of pain; Theme 3: Providers attempt to recalibrate the patient's reported experience to reflect their own understanding of pain; and Theme 4: Providers perceive that some patients may overreport their pain because they do not know how to standardize their subjective experience.

CONCLUSIONS

A persistent challenge to pain assessment and management is how clinicians reconcile a patient's subjective self-reported experience with their own clinical assessment and personal biases. Future work should explore these themes from the patient perspective.

A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO

Background

Chronic pain conditions are complicated and challenging to live with. Electronic health (eHealth) interventions show promise in helping people cope with chronic illness, including pain. The success of these interventions depends not only on the technology and intervention content but also on the users’ acceptance and adherence. Involving all stakeholders (eg, patients, spouses, health care providers, designers, software developers, and researchers) and exploring their input and preferences in the design and development process is an important step toward developing meaningful interventions and possibly strengthening treatment outcomes.

Objective

The aim of this study was to design and develop a user-centered, evidence-based eHealth self-management intervention for people with chronic pain.

Methods

The study employed a multidisciplinary and user-centered design approach. Overall, 20 stakeholders from the project team (ie, 7 researchers, 5 editors, 7 software developers, and 1 user representative), together with 33 external stakeholders (ie, 12 health care providers, 1 health care manger, 1 eHealth research psychologist, and 17 patients with chronic pain and 2 of their spouses) participated in a user-centered development process that included workshops, intervention content development, and usability testing. Intervention content was developed and finalized based on existing evidence, stakeholder input, and user testing. Stakeholder input was examined through qualitative analyses with rapid and in-depth analysis approaches.

Results

Analyses from stakeholder input identified themes including a need for reliable, trustworthy, and evidence-based content, personalization, options for feedback, behavioral tracking, and self-assessment/registration as factors to include in the intervention. Evidence-based intervention content development resulted in one face-to-face introduction session and 9 app-based educational and exercise-based modules. Usability testing provided further insight into how to optimize the design of the intervention to the user group, identifying accessibility and a simple design to be essential.

Conclusions

The design and development process of eHealth interventions should strive to combine well-known evidence-based concepts with stakeholder input. This study, designing and developing the pain management intervention EPIO, illustrates how a stakeholder-centered design approach can provide essential input in the development of an eHealth self-management intervention for people with chronic pain.

Trial Registration

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104

What Do Providers Want from a Pain Screening Measure Used in Daily Practice?

Objectives

We aimed to understand providers' experiences and preferences regarding several brief pain screening measures.

Methods

We collected two waves of data for this analysis. Wave one: We conducted nine focus groups with multidisciplinary Department of Veterans Affairs (VA) providers. Wave two: To understand an emergent theme in wave one, we conducted 15 telephone interviews with prescribing providers where we used a semistructured guide comparing screening measures currently used in VA practices. Using content analysis of the wave two interviews, we evaluated providers' perceptions of important aspects of brief pain screening measures and reported emergent themes.

Results

Five emergent themes underlie providers' perceptions of the utility of brief pain screening measures: 1) item abstractness: how bounded and concrete a patient's interpretation of an individual item is; 2) item distinctness: belief in the patient's ability to differentiate between the meaning of various items in a pain measure; 3) item anchoring: presence of a description under each response option making the meaning explicit; 4) item look-back period: the period of time over which patients are asked to remember and comment on their pain; 5) parsimony: identifying the shortest and simplest approach possible to acquire desired information.

Conclusions

Overly complex or adaptive screening tools may include information that is ultimately not used by providers. Conversely, overly simplistic pain screening tools may omit information that helps providers understand the impact of pain on patients' lives. As pain is nuanced, complex, and subjective, all screening measures exhibit some limitations. No single pain measure serves all chronic pain patients, and specific contexts or settings may warrant additional specific items.

Pain vs. comfort diary: A fully remote app-based experiment

BACKGROUND

Focusing on pain while completing a pain diary might have detrimental effects on pain intensity. Inverted comfort ratings might be used instead.

METHODS

A fully remote app-based registered experiment was conducted to investigate the effects of a pain versus comfort diary on 7-day recall ratings of pain intensity during a 3-week period. The diary included questions about past, current and expected pain or comfort. Randomization took place by the study app, thereby controlling for effects of experimenter bias.

RESULTS

Contrary to the study hypothesis, multilevel regression showed a more pronounced decrease in 7-day recall ratings of pain in the group who rated pain intensity daily (n = 184) than in the group who rated comfort daily (n = 205, B = -0.17, p = 0.034). There were no between-group differences in secondary outcomes (comfort, depressive symptoms, pain interference and happiness). Exploratory analyses revealed more pronounced decreases in pain intensity in participants who experienced less frequent pain in the previous 6 months. Correlations between pain and comfort ratings decreased from -0.39 at baseline to -0.06 after 3 weeks.

CONCLUSIONS

The findings do not support the potential beneficial effects of replacing diary ratings of pain intensity with diary ratings of comfort. The unexpected decreases among those who completed daily pain diaries might have been due to the inclusion of questions about expected pain. Decreasing correlations between pain and comfort ratings suggest that comfort ratings are not merely inverted pain ratings; rather, they appear to assess a domain distinct from pain intensity.

SIGNIFICANCE

The positive effects of pain diaries on pain trajectories appear to constitute a reliable effect and not a methodological artefact. Pain diaries should be investigated systematically to identify ways to optimize their effects on clinical outcomes. Comfort diaries, however, do not appear to be an efficacious substitute for pain diaries; if the current findings replicate, they indicate that primary care practitioners should continue to use pain diaries in clinical care.

Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid management

BACKGROUND

Facilitating appropriate and safe prescribing of opioid medications for chronic pain management in primary care is a pressing public health concern. Interdisciplinary team-based models of primary care are exploring the expansion of clinical pharmacist roles to support disease management for chronic conditions, e.g. pain. Our study aims to 1) identify roles clinical pharmacists can assume in primary care team based chronic pain care processes and 2) understand the barriers to assuming these expanded roles.

METHODS

Setting: Veterans Health Administration (VA) has implemented an interdisciplinary team-based model for primary care which includes clinical pharmacists.

DESIGN

We employed an inductive two part qualitative approach including focus groups and semi-structured interviews with key informants.

PARTICIPANTS

60 members of VA primary care teams in two states participated in nine preliminary interdisciplinary focus groups where a semi-structured interview guide elucidated provider experiences with screening for and managing chronic pain. To follow up on emergent themes relating to clinical pharmacist roles, an additional 14 primary care providers and clinical pharmacists were interviewed individually. We evaluated focus group and interview transcripts using the method of constant comparison and produced mutually agreed upon themes.

RESULTS

Clinical pharmacists were identified by primary care providers as playing a central role with the ongoing management of opioid therapy including review of the state prescription drug monitoring program, managing laboratory screening, providing medication education, promoting naloxone use, and opioid tapering. Specific barriers to clinical pharmacists role expansion around pain care include: limitations of scopes of practice, insufficient institutional support (low staffing, dedicated time, insufficient training, lack of interdisciplinary leadership support), and challenges and opportunities for disseminating clinical pharmacists' expanded roles.

CONCLUSIONS

Expanding the role of the clinical pharmacist to collaborate with providers around primary care based chronic pain management is a promising strategy for improving pain management on an interdisciplinary primary care team. However, expanded roles have to be balanced with competing responsibilities relating to other conditions. Interdisciplinary leadership is needed to facilitate training, resources, adequate staffing, as well as to prepare both clinical pharmacists and the providers they support, about expanded clinical pharmacists' scopes of practice and capabilities.