Self-management support and communication from nurse care managers compared with primary care physicians: a focus group study of patients with chronic musculoskeletal pain

Healthcare Access and Delivery During the COVID-19 Pandemic for Black Veterans with Chronic Pain: a Qualitative Study

BACKGROUND

The COVID-19 pandemic led to significant disruptions in healthcare and rapid increases in virtual healthcare delivery. The full effects of these shifts remain unknown. Understanding effects of these disruptions is particularly relevant for patients with chronic pain, which typically requires consistent engagement in treatment to maximize benefit, and for Black patients, given documented racial disparities in pain treatment and telehealth delivery.

OBJECTIVE

To understand how Black patients with chronic pain experienced pandemic-related changes in healthcare delivery.

DESIGN

In-depth, semi-structured qualitative interviews PARTICIPANTS: Black veterans with chronic pain.

KEY RESULTS

Participants described decreased ability to self-manage their chronic pain, obtain nonpharmacological services such as physical therapy, see their primary care providers, and schedule surgery. Most did not believe telehealth met their needs, describing feeling inadequately assessed for their pain and noting that beyond renewing prescriptions, telehealth visits were not that useful. Some believed their communication with their providers suffered from a lack of in-person contact. Others, however, were willing to accept this tradeoff to prevent possible exposure to COVID-19, and some appreciated the convenience of being able to access healthcare from home.

CONCLUSIONS

Black patients with chronic pain described mostly negative effects from the shift to telecare after the pandemic's onset. Given existing disparities and likely persistence of virtual care, research on the longer-term effects of virtual pain care for Black patients is needed.

Examining how physician factors influence patient satisfaction during clinical consultations about cancer prognosis and pain

Objective

Patient-physician communication affects cancer patients' satisfaction, health outcomes, and reimbursement for physician services. Our objective is to use machine learning to comprehensively examine the association between patient satisfaction and physician factors in clinical consultations about cancer prognosis and pain.

Methods

We used data from audio-recorded, transcribed communications between physicians and standardized patients (SPs). We analyzed the data using logistic regression (LR) and random forests (RF).

Results

The LR models suggested that lower patient satisfaction was associated with more in-depth prognosis discussion; and higher patient satisfaction was associated with a greater extent of shared decision making, patient being black, and doctor being young. Conversely, the RF models suggested the opposite association with the same set of variables.

Conclusion

Somewhat contradicting results from distinct machine learning models suggested possible confounding factors (hidden variables) in prognosis discussion, shared decision-making, and doctor age, on the modeling of patient satisfaction. Practitioners should not make inferences with one single data-modeling method and enlarge the study cohort to help deal with population heterogeneity.

Innovation

Comparing diverse machine learning models (both parametric and non-parametric types) and carefully applying variable selection methods prior to regression modeling, can enrich the examination of physician factors in characterizing patient-physician communication outcomes.

Patient perspectives on primary care for multimorbidity: An integrative review

INTRODUCTION

Improving healthcare for people with multiple chronic or ongoing conditions is receiving increased attention, particularly due to the growing number of people experiencing multimorbidity (MM) and concerns about the sustainability of the healthcare system. Primary care has been promoted as an important resource for supporting people with MM to live well with their conditions and to prevent unnecessary use of health care services. However, traditional primary care has been criticized for not centring the needs and preferences of people with MM themselves. Our aim was to conduct a review that centred on the perspective of people with MM in multiple ways, including having patient partners co-lead the design, conduct and reporting of findings, and focusing on literature that reported the perspective of people with MM, irrespective of it being experimental or nonexperimental.

METHODS

We searched for published literature in CINAHL with Full Text (EBSCOhost) and MEDLINE All (Ovid). Findings from experimental and nonexperimental studies were integrated into collaboration with patient partners.

RESULTS

Twenty-nine articles were included in the review. Findings are described in five categories: (1) Care that is tailored to my unique situation; (2) meaningful inclusion in the team; (3) a healthcare team that is ready and able to address my complex needs; (4) supportive relationships and (5) access when and where I need it.

CONCLUSION

This review supports a reorientation of primary care systems to better reflect the experiences and perspectives of people with MM. This can be accomplished by involving patient partners in the design and evaluation of primary care services and incentivizing collaboration among health and social supports and services for people with MM.

PATIENT OR PUBLIC CONTRIBUTION

Patient partners were involved in the design and conduct of this review, and in the preparation of the manuscript. Their involvement is further elucidated in the manuscript text.

Exploring the relationships among social support, patient activation, and pain-related outcomes

OBJECTIVE

Social support has been linked to more effective pain adaptation. The relationship between social support and other relevant constructs is less well-understood. Chief among these is patient activation, which has robust links to effective self-management, yet has not been well-studied in chronic pain. We sought to better understand these relationships in an effort to inform future intervention strategies for patients with chronic pain.

METHODS

Using baseline data from a clinical trial with patients with chronic pain (N = 213), we analyzed the relationships among perceived social support and patient activation, depression, anxiety, general health perceptions, pain centrality, pain catastrophizing, and pain intensity and interference. Multiple linear regression was used to examine the effect of social support on outcomes. Patient activation was explored as a mediator of the effect of social support on outcomes.

RESULTS

Social support was significantly associated with all outcomes except pain. Social support explained the greatest variance in patient activation (squared semi-partial correlation =0.081), followed by depression (0.073) and general health perceptions (0.072). Patient activation was not found to be a significant mediator of the effect of social support on pain-related outcomes.

CONCLUSIONS

Findings provide insight into the roles of patient activation and social support in chronic pain management. Although patient activation did not mediate the relationship between social support and outcomes, this study is an important step toward gaining a more complete understanding of constructs thought to be related to pain self-management and points to the need to advance theory in this area to guide future research. Such work is needed to optimize interventions for patients with chronic pain.

Pain and Depression Symptoms During the Third Trimester of Pregnancy

PURPOSE

To assess the association between depression symptoms and pain characteristics, including pain intensity, location, and effectiveness of pain management strategies, among women in their third trimester of pregnancy.

DESIGN

Descriptive, exploratory cross-sectional study.

SETTING

Mobile health pregnancy application (app).

PARTICIPANTS

A convenience sample of women in their third trimester of pregnancy from across the United States.

METHODS

Women completed demographic questionnaires, the Brief Pain Inventory, and Edinburgh Postnatal Depression Scale (EPDS) through an online Web site.

RESULTS

N = 132 women participated. The sample was demographically diverse. . Women ranged in age from 18 to 39 years (M 28.1 ± SD 5.2). Most women were Caucasian (68%), with smaller percentages of Hispanic (12%) and African American (11%) women. Most had commercial insurance (59%) and a partner (85%). Of the 132 women, 79.6% reported moderate-to-severe pain. Approximately 93% experienced back and pelvic pain, whereas 27% experienced moderate-to-severe depression symptoms. Bivariate and linear regression analyses revealed that higher EPDS depression scores were associated with higher levels of pain (p < .01). Other variables significantly associated with higher EPDS scores were White race (p = .04), marital status (p = .05), and headache (p < .01).

CLINICAL IMPLICATIONS

In the third trimester of pregnancy, pain affects more than two-thirds of women and may occur with and without depression symptoms. Although the value of universal depression screening during pregnancy is widely recognized, our findings suggest clinical outcomes for pregnant women would improve with a standardized, multidimensional screen for both pain and depression symptoms. Nurses are ideally positioned to assess and advocate for the combined treatment of pain and depression.

Peer Support for Self-Management of Chronic Pain: the Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE) Trial

BACKGROUND

Pain self-management is an effective, evidence-based treatment for chronic pain. Peer support, in which patients serve as coaches for other patients, has been effective in other chronic conditions and is a potentially promising approach to implementing pain self-management programs using fewer clinical resources.

OBJECTIVE

To test a peer coach-delivered pain self-management program for chronic pain.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Veterans with chronic musculoskeletal pain.

INTERVENTION

Intervention patients were assigned a trained peer coach for 6 months. Coaches, who were volunteers, were asked to contact their assigned patients, either by phone or in person, twice per month. Coaches and patients were given an intervention manual to guide sessions. The control group was offered a 2-hour pain self-management class.

MAIN MEASURES

The primary outcome was total pain, assessed by the Brief Pain Inventory (BPI). Secondary outcomes were anxiety, depression, pain catastrophizing, self-efficacy, social support, patient activation, health-related quality of life, and healthcare utilization. Outcomes were measured at baseline, 6 months, and 9 months.

KEY RESULTS

Two hundred fifteen patients enrolled (120 intervention, 95 control). Adherence to intervention protocol was low, with only 13% of patients reporting having at least the recommended 12 peer coach meetings over the 6-month intervention. BPI total decreased from baseline to 6 months and baseline to 9 months in both groups. At 9 months, this change was statistically significant (intervention, - 0.40, p = 0.018; control, - 0.47, p = 0.006). There was not a statistically significant difference between groups on BPI at either time point. No secondary outcomes improved significantly in either group after adjusting for multiple comparisons.

CONCLUSIONS

Patients randomized to peer support did not differ from control patients on primary and secondary outcomes. Other peer support models that do not rely on volunteers might be more effective.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02380690.

Patients' Experiences with Telecare for Chronic Pain and Mood Symptoms: A Qualitative Study

OBJECTIVE

Pain, anxiety, and depression commonly co-occur, can have reciprocal effects, and are associated with substantial disability and health care costs. However, few interventions target treatment of pain and mood disorders as a whole. The Comprehensive vs. Assisted Management of Mood and Pain Symptoms (CAMMPS) trial was a randomized trial comparing two pragmatic telecare interventions, a high- vs low-resource approach to pain and anxiety/depression treatment. The purpose of the current study is to better understand patients' perspectives on both intervention approaches, including intervention components, delivery, patient experiences, and patient outcomes.

DESIGN

Qualitative, semistructured interviews.

SETTING

A Veterans Affairs Medical Center.

SUBJECTS

Twenty-five patients were purposefully sampled from both study arms.

METHODS

Patients were interviewed about their experiences with pain and mood treatment, perceived benefits and changes, and experiences with the intervention model to which they were randomized. The constant comparison method guided analysis.

RESULTS

Pain was more important than mood for most participants. Participants described developing increased awareness of their symptoms, including connecting pain and mood, which enabled better management. Participants in the high-resource intervention described the added value of the study nurse in their symptom management.

CONCLUSIONS

Patients in a telecare intervention for chronic pain and mood symptoms learned to connect pain and mood and be more aware of their symptoms, enabling more effective symptom management. Patients in the high-resource intervention described the added benefits of a nurse who provided informational and motivational support. Implications for tradeoffs between resource intensity and patient outcomes are discussed.

Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making?

Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan's SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.

Exploring peer coaches' outcomes: Findings from a clinical trial of patients with chronic pain

OBJECTIVE

Although peer coaching can help patients manage chronic conditions, few studies have evaluated the effects of peer coaching on coaches, and no studies have systematically examined these effects in the context of chronic pain coaching.

METHODS

Peer coach outcomes were assessed as part of a randomized trial of peer coaching for chronic pain. In this exploratory analysis, linear mixed models were used to evaluate changes in peer coaches' pain and related outcomes from baseline to 6 and 9 months. The Šidák method was used to account for multiple comparisons.

RESULTS

Peer coaches (N = 55) experienced statistically significant increases in anxiety and pain catastrophizing from baseline to 6 months, which were no longer significant after adjustment. All other changes were not statistically significant.

CONCLUSIONS

Despite prior studies suggesting that peer coaches benefit from serving as a coach, the current study failed to support that conclusion.

PRACTICE IMPLICATIONS

Peer coaching remains a promising model, with high potential for implementation, for a number of chronic conditions requiring self-management. However, to maximize the benefits of such interventions, it is essential to monitor both those being coached and the coaches themselves, and not to assume that serving as a coach is inherently beneficial.

Evaluation of a peer coach-led intervention to improve pain symptoms (ECLIPSE): Rationale, study design, methods, and sample characteristics

Chronic pain is prevalent, costly, and a leading cause of disability. Pain self-management (i.e., employing self-management strategies including behavioral modifications) is an effective, evidence-based treatment. However, implementation and delivery of a pain self-management model is challenging because of time and resources. Peer supported pain self-management offers a promising approach to implementing pain self-management programs using fewer clinical resources. Evaluation of a Peer Coach-Led Intervention for the Improvement of Pain Symptoms (ECLIPSE) is a randomized controlled trial testing effectiveness of peer coach-delivered pain self-management intervention versus controls receiving a class on pain and pain self-management. ECLIPSE is a Hybrid Type 1 study testing effectiveness while examining implementation factors. ECLIPSE enrolled 215 veterans randomly assigned to the peer coaching (N = 120) or control (N = 95) arm. The peer coaching intervention lasts 6 months, with patient-peer coach pairs instructed to talk twice per month. Coaches attend initial training, are provided a detailed training manual, and attend monthly booster sessions. Outcomes are assessed at baseline, 6 months, and 9 months. The primary outcome is overall pain (intensity and interference), measured by the Brief Pain Inventory (BPI). Secondary outcomes are self-efficacy, social support, pain catastrophizing, patient activation, health-related quality of life, and health care utilization. To maximize implementation potential of pain self-management, innovative delivery methods are needed that do not require additional resources from healthcare teams. A novel and promising approach is a peer-coaching model, in which patients who are successfully managing their pain offer information, ongoing support, and advice to other patients with pain. Clinical Trials Registration: NCT02380690.

Perspective of Pain Clinicians in Three Global Cities on Local Barriers to Providing Care for Chronic Noncancer Pain Patients

An increasing proportion of the global chronic pain population is managed through services delivered by specialized pain clinics in global cities. This paper describes the results of a survey of pain clinic leaders in three global cities on barriers influencing chronic noncancer pain (CNCP) management provided by those clinics. It demonstrates a pragmatic qualitative approach for characterizing how the global city location of the clinic influences those results. A cross-sectional prospective survey design was used, and data were analyzed using quantitative and qualitative content analysis. Key informants were pain clinicians (n = 4 women and 8 men) responsible for outputs of specialized pain clinics in academic hospital settings in three global cities: Toronto, Kuwait, and Karachi. Krippendorff's thematic clustering technique was used to identify the repetitive themes in the data. All but one of the key informants had their primary pain training from Europe or North America. In Kuwait and Karachi, pain specialists were anesthesiologists and provided CNCP management services independently. In Toronto, pain clinic leaders were part of some form of the multidisciplinary team. Using the results of a question that asked informants to list their top three barriers, ten themes were identified. These themes were artificially organized in three thematic domains: infrastructure, clinical services, and education. In parallel, 31 predefined barriers identified from the literature were scored. The results showed variation in perception of barriers that not only depended on the clinic location but also demonstrated shared experiences across thematic domains. This study demonstrates a simple methodology for informing global and local efforts to improve access to and implementation of CNCP services globally.

"I Was a Little Surprised": Qualitative Insights From Patients Enrolled in a 12-Month Trial Comparing Opioids With Nonopioid Medications for Chronic Musculoskeletal Pain

Chronic musculoskeletal pain is a major public health problem. Although opioid prescribing for chronic pain has increased dramatically since the 1990s, this practice has come under scrutiny because of increases in opioid-related harms and lack of evidence for long-term effectiveness. The Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial was a pragmatic 12-month randomized trial comparing the benefits and harms of opioid versus nonopioid medications for chronic musculoskeletal pain. The current qualitative study was designed to better understand trial results by exploring patients' experiences, including perceptions of medications, experiences with the intervention, and whether expectations were met. Thirty-four participants who were purposefully sampled based on treatment group and intervention response participated in semistructured interviews. The constant comparison method guided analysis. Results revealed that participants often held strong beliefs about opioid medications, which sometimes changed during the trial as they gained experience with medications; participants described a wide variety of experiences with treatment effectiveness, regardless of study group or their response to the intervention; and participants highly valued the personalized pain care model used in SPACE.

PERSPECTIVE

SPACE trial results indicated no advantage for opioid over nonopioid medications. Qualitative findings suggest that, for both treatment groups, preexisting expectations and anticipated improvement in pain shaped experiences with and responses to medications. The personalized pain care model was described as contributing to positive outcomes in both groups.

Patient-Centered Pain Management Communication from the Patient Perspective

BACKGROUND

Pain management discussions between patient and provider can be stressful to navigate and greatly impact the care received. Because of the complexity, emotional color, and sensitivity of pain management, such discussions require a high degree of skill.

OBJECTIVE

To identify patients' perspectives of patient-centered care communication within the context of pain management discussions.

DESIGN

We conducted semi-structured interviews (25-65 min) with patients regarding their experiences with pain assessment and management.

PARTICIPANTS

36 patients (29 males, 7 females), from 3 Veteran Affairs healthcare locations. Participant age ranged from 28 to 94 with pain intensity ranging from 0 to 10, based on the "pain now" numeric rating scale report gathered at the time of the interview.

APPROACH

Interview transcript analysis was conducted using the constant comparison method to produce mutually agreed upon themes.

KEY RESULTS

Elements of patient-centered care communication described by participants include judgment, openness, listening, trust, preferences, solution-oriented, customization, and longevity. Patients perceive provider reciprocation in openness and trust as drivers of the patient-provider relationship, thereby enhancing positive, associated themes.

CONCLUSIONS

Findings highlight the importance of the patient-provider relationship in patient-centered care and offer patient-centered care communication tools for practitioners to utilize, such as solution-oriented messages and communicating trust, especially when interacting with patients about pain.

Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain: a Rapid Evidence Review

BACKGROUND

Primary care providers (PCPs) face many system- and patient-level challenges in providing multimodal care for patients with complex chronic pain as recommended in some pain management guidelines. Several models have been developed to improve the delivery of multimodal chronic pain care. These models vary in their key components, and work is needed to identify which have the strongest evidence of clinically-important improvements in pain and function. Our objective was to determine which primary care-based multimodal chronic pain care models provide clinically relevant benefits, define key elements of these models, and identify patients who are most likely to benefit.

METHODS

To identify studies, we searched MEDLINE® (1996 to October 2016), CINAHL, reference lists, and numerous other sources and consulted with experts. We used predefined criteria for study selection, data abstraction, internal validity assessment, and strength of evidence grading.

RESULTS

We identified nine models, evaluated in mostly randomized controlled trials (RCTs). The RCTs included 3816 individuals primarily from the USA. The most common pain location was the back. Five models primarily coupling a decision-support component-most commonly algorithm-guided treatment and/or stepped care-with proactive ongoing treatment monitoring have the best evidence of providing clinically relevant improvement in pain intensity and pain-related function over 9 to 12 months (NNT range, 4 to 13) and variable improvement in quality of life, depression, anxiety, and sleep. The strength of the evidence was generally low, as each model was only supported by a single RCT with imprecise findings.

DISCUSSION

Multimodal chronic pain care delivery models coupling decision support with proactive treatment monitoring consistently provide clinically relevant improvement in pain and function. Wider implementation of these models should be accompanied by further evaluation of clinical and implementation effectiveness.

Patients' Perception of Chronic-Pain-Related Patient-Provider Communication in Relation to Sociodemographic and Pain-Related Variables: A Cross-Sectional Nationwide Study

Pain is a personal experience and patient-provider communication therefore an essential part of diagnosis and treatment where the patient's perspective needs to be central. The aim of this descriptive cross-sectional study was to investigate chronic-pain-related patient-provider communication in the context of sociodemographic variables, pain variables, perceived outcome of care, and satisfaction with health care providers. A postal questionnaire measuring socio-demographic variables, pain characteristics, pain-related health care utilization and patient-provider communication was sent to a sample of 4,500 individuals randomly drawn from the national population of Iceland. A subsample reporting chronic pain and having visited a health care provider for pain the previous six months (n = 401) was analyzed. Relationships between patient-provider communication and other measured variables were tested using bivariate and multivariate statistics. The more chronic pain impaired health-related quality of life, the more provider control the patients perceived in the patient-provider communication. There was also a strong negative relationship between patients' perception of providers' support and openness to discussing symptoms, and satisfaction with health care provider. Patients' perception of their own control in patient-provider communication and involvement in decisions regarding care was related to sociodemographic variables (specifically, education and residence) but not to pain related variables. This study highlights the importance of assessing chronic pain in a broad spectrum, listening, and giving patients time and support to communicate chronic pain and how it affects their life situation. The more interfering the pain is, the more important this is.

Facilitators and Barriers to Participation in a Peer Support Intervention for Veterans With Chronic Pain

OBJECTIVE

To understand facilitators and barriers to participation in a peer support intervention for self-management of chronic pain.

METHODS

After completing a pilot intervention study, peer coaches and their veteran patients took part in a qualitative, semistructured interview to explore their experiences with the intervention. Data were analyzed using an immersion/crystallization approach.

RESULTS

Three facilitators and 2 barriers to patient participation in a peer support intervention for veterans with chronic pain emerged. Facilitators were (1) having a shared identity as veterans, (2) being partnered with a person who also has chronic pain, and (3) support from the study staff. Barriers were (1) logistical challenges, and (2) challenges to motivation and engagement in the intervention.

DISCUSSION

Awareness of facilitators and barriers to participation in a peer-supported self-management program for chronic pain, as well as strategies to capitalize on facilitators and mitigate barriers, are essential for further study and ultimate clinical implementation of such a program.

Patient-professional partnerships and chronic back pain self-management: a qualitative systematic review and synthesis

Chronic back pain is common, and its self-management may be a lifelong task for many patients. While health professionals can provide a service or support for pain, only patients can actually experience it. It is likely that optimum self-management of chronic back pain may only be achieved when patients and professionals develop effective partnerships which integrate their complementary knowledge and skills. However, at present, there is no evidence to explain how such partnerships can influence patients' self-management ability. This review aimed to explore the influence of patient-professional partnerships on patients' ability to self-manage chronic back pain, and to identify key factors within these partnerships that may influence self-management. A systematic review was undertaken, aiming to retrieve relevant studies using any research method. Five databases were searched for papers published between 1980 and 2014, including Cochrane Library, CINAHL, Medline, EMBASE and PsycINFO. Eligible studies were those reporting on patients being supported by professionals to self-manage chronic back pain; patients being actively involved for self-managing chronic back pain; and the influence of patient-professional partnerships on self-management of chronic back pain. Included studies were critically appraised for quality, and findings were extracted and analysed thematically. A total of 738 studies were screened, producing 10 studies for inclusion, all of which happened to use qualitative methods. Seven themes were identified: communication, mutual understanding, roles of health professionals, information delivery, patients' involvement, individualised care and healthcare service. These themes were developed into a model suggesting how factors within patient-professional partnerships influence self-management. Review findings suggest that a partnership between patients and professionals supports patients' self-management ability, and effective communication is a fundamental factor underpinning their partnerships in care. It also calls for the development of individualised healthcare services offering self-referral or telephone consultation to patients with chronic conditions.

Stepped care model of pain management and quality of pain care in long-term opioid therapy

Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.

A Systematic Review of Patients' Experiences in Communicating with Primary Care Physicians: Intercultural Encounters and a Balance between Vulnerability and Integrity

Communication difficulties persist between patients and physicians. In order to improve care, patients’ experiences of this communication must be understood. The main objective of this study is to synthesize qualitative studies exploring patients’ experiences in communicating with a primary care physician. A secondary objective is to explore specific factors pertaining to ethnic minority or majority patients and their influence on patients’ experiences of communication. Pertinent health and social sciences electronic databases were searched systematically (PubMed, Cinahl, PsychNet, and IBSS). Fifty-seven articles were included in the review on the basis of being qualitative studies targeting patients’ experiences of communication with a primary care physician. The meta-ethnography method for qualitative studies was used to interpret data and the COREQ checklist was used to evaluate the quality of included studies. Three concepts emerged from analyses: negative experiences, positive experiences, and outcomes of communication. Negative experiences related to being treated with disrespect, experiencing pressure due to time constraints, and feeling helpless due to the dominance of biomedical culture in the medical encounter. Positive experiences are attributed to certain relational skills, technical skills, as well as certain approaches to care privileged by the physician. Outcomes of communication depend on patients’ evaluation of the consultation. Four categories of specific factors exerted mainly a negative influence on consultations for ethnic minorities: language barriers, discrimination, differing values, and acculturation. Ethnic majorities also raised specific factors influencing their experience: differing values and discrimination. Findings of this review are limited by the fact that more than half of the studies did not explore cultural aspects relating to this experience. Future research should address these aspects in more detail. In conclusion, all patients seemed to face additional cultural challenges. Findings provide a foundation for the development of tailored interventions to patients’ preferences, thus ensuring more satisfactory experiences. Health care providers should be sensitive to specific factors (cultural and micro-cultural) during all medical encounters.

Self-management support for chronic pain in primary care: a cross-sectional study of patient experiences and nursing roles

AIMS

The aim of this study was to describe chronic pain self-management from the perspective of individuals living with chronic pain in the context of primary care nursing.

BACKGROUND

Self-management is a key chronic pain treatment modality and support for self-managing chronic pain is mainly provided in the context of primary care. Although nurses are optimally suited to facilitate self-management in primary care, there is a need to explore opportunities for optimizing their roles.

DESIGN

Two cross-sectional studies.

METHODS

The Chronic Pain Self-Management Survey was conducted in 2011-2012 to explore the epidemiology and self-management of chronic pain in Canadian adults. The questionnaire was distributed to 1504 individuals in Ontario. In 2011, the Primary Care Nursing Roles Survey was distributed to 1911 primary care nurses in Ontario to explore their roles and to determine the extent to which chronic disease management strategies, including support for self-management, were implemented in primary care.

RESULTS

Few respondents to the pain survey identified nurses as being the 'most helpful' facilitator of self-management while physicians were most commonly cited. Seventy-six per cent of respondents used medication to manage their chronic pain. Few respondents to the nursing survey worked in practices with specific programmes for individuals with chronic pain. Individuals with chronic pain identified barriers and facilitators to self-managing their pain and nurses identified barriers and facilitators to optimizing their role in primary care.

CONCLUSION

There are several opportunities for primary care practices to facilitate self-management of chronic pain, including the optimization of the primary care nursing role.

A brief peer support intervention for veterans with chronic musculoskeletal pain: a pilot study of feasibility and effectiveness

OBJECTIVE

The aim of this study was to pilot test a peer support intervention, involving peer delivery of pain self-management strategies, for veterans with chronic musculoskeletal pain.

DESIGN

Pretest/posttest with 4-month intervention period.

METHODS

Ten peer coaches were each assigned 2 patients (N = 20 patients). All had chronic musculoskeletal pain. Guided by a study manual, peer coach-patient pairs were instructed to talk biweekly for 4 months. Pain was the primary outcome and was assessed with the PEG, a three-item version of the Brief Pain Inventory, and the PROMIS Pain Interference Questionnaire. Several secondary outcomes were also assessed. To assess change in outcomes, a linear mixed model with a random effect for peer coaches was applied.

RESULTS

Nine peer coaches and 17 patients completed the study. All were male veterans. Patients' pain improved at 4 months compared with baseline but did not reach statistical significance (PEG: P = 0.33, ICC [intra-class correlation] = 0.28, Cohen's d = -0.25; PROMIS: P = 0.17, d = -0.35). Of secondary outcomes, self-efficacy (P = 0.16, ICC = 0.56, d = 0.60) and pain centrality (P = 0.06, ICC = 0.32, d = -0.62) showed greatest improvement, with moderate effect sizes.

CONCLUSIONS

This study suggests that peers can effectively deliver pain self-management strategies to other veterans with pain. Although this was a pilot study with a relatively short intervention period, patients improved on several outcomes.

Assisting Older Persons With Adjusting to Hearing Aids

This intervention study tested the feasibility and initial effect of Hearing Aid Reintroduction (HEAR) to assist persons aged 70 to 85 years adjust to hearing aids. Following this 30-day intervention, hearing aid use increased between 1 and 8 hr per day with 50% of participants able to wear them for at least 4 hr. Hearing aid satisfaction improved from not satisfied to satisfied overall. The study demonstrated that HEAR is feasible and could improve hearing aid use of a substantial number of older persons who had previously failed to adjust to their hearing aids and had given up. However, further testing among a larger and more diverse population is needed to better understand the effectiveness and sustainability of the intervention.

Hearing new voices: registered nurses and health technicians experience caring for chronic pain patients in primary care clinics

Recent national estimates from the U.S. reveal that as many as one-third of all Americans experience chronic pain resulting in high prevalence rates of visits to primary care clinics (PCC). Indeed, chronic pain appears to be an emerging global health problem. Research has largely ignored the perspective of PCC staff other than physicians in providing care for patients with chronic pain. We wanted to gain insights from the experiences of Registered Nurses (RNs) and Health Technicians (HTs) who care for this patient population. Krippendorff’s method for content analysis was used to analyze comments written in an open-ended survey from fifty-seven primary care clinic staff (RNs-N=27 and HTs-N=30) respondents. This represented an overall response rate of 75%. Five themes emerged related to the experience of RNs and HTs caring for patients with chronic pain: 1) Primacy of Medications and Accompanying Clinical Quandaries; 2) System Barriers; 3) Dealing with Failure; 4) Primacy of Patient Centered Care; and 5) Importance of Team Based Care. This study demonstrates that nursing staff provide patient-centered care, recognize the importance of their role within an interdisciplinary team and can offer valuable insight about the care of patients with chronic pain. This study provides insight into strategies that can mitigate barriers to chronic pain management while sustaining those aspects that RNs and HTs view as essential for improving patient care for this vulnerable population in PCCs.

Development and application of an electronic health record information extraction tool to assess quality of pain management in primary care

Chronic pain is one of the most common presenting problems in primary care. Standards and guidelines have been developed for managing chronic pain, but it is unclear whether primary care providers routinely engage in guideline-concordant care. The purpose of this study is to develop a tool for extracting information about the quality of pain care in the primary care setting. Quality indicators were developed through review of the literature, input from an interdisciplinary panel of pain experts, and pilot testing. A comprehensive coding manual was developed, and inter-rater reliability was established. The final tool consists of 12 dichotomously scored indicators assessing quality and documentation of pain care in three domains: assessment, treatment, and reassessment. Presence of indicators varied widely. The tool is reliable and can be utilized to gather valuable information about pain management in the primary care setting.

Self-management interventions for chronic pain

SUMMARY Individuals living with chronic pain face daily challenges of managing symptoms, modifying roles and responsibilities, and coping with the negative emotional consequences of pain. Self-management interventions teach a variety of strategies to meet these challenges and build participants' self-efficacy for their use. These interventions have been delivered in individual, group and online formats for a variety of different pain conditions. The evidence supports the efficacy of self-management interventions in improving pain, mental health and health-related quality of life outcomes. Acceptance of the chronic nature of their pain is a necessary step before individuals are ready to self-manage. Clinicians can play a critical role in supporting self-management through answering questions, providing advice, addressing barriers and facilitators, and encouraging self-management efforts.

Perspectives of older adults on co-management of low back pain by doctors of chiropractic and family medicine physicians: a focus group study

Background

While older adults may seek care for low back pain (LBP) from both medical doctors (MDs) and doctors of chiropractic (DCs), co-management between these providers is uncommon. The purposes of this study were to describe the preferences of older adults for LBP co-management by MDs and DCs and to identify their concerns for receiving care under such a treatment model.

Methods

We conducted 10 focus groups with 48 older adults who received LBP care in the past year. Interviews explored participants’ care seeking experiences, co-management preferences, and perceived challenges to successful implementation of a MD-DC co-management model. We analyzed the qualitative data using thematic content analysis.

Results

Older adults considered LBP co-management by MDs and DCs a positive approach as the professions have complementary strengths. Participants wanted providers who worked in a co-management model to talk openly and honestly about LBP, offer clear and consistent recommendations about treatment, and provide individualized care. Facilitators of MD-DC co-management included collegial relationships between providers, arrangements between doctors to support interdisciplinary referral, computer systems that allowed exchange of health information between clinics, and practice settings where providers worked in one location. Perceived barriers to the co-management of LBP included the financial costs associated with receiving care from multiple providers concurrently, duplication of tests or imaging, scheduling and transportation problems, and potential side effects of medication and chiropractic care. A few participants expressed concern that some providers would not support a patient-preferred co-managed care model.

Conclusions

Older adults are interested in receiving LBP treatment co-managed by MDs and DCs. Older adults considered patient-centered communication, collegial interdisciplinary interactions between these providers, and administrative supports such as scheduling systems and health record sharing as key components for successful LBP co-management.

An overview of the management of persistent musculoskeletal pain

Musculoskeletal pain is a common reason for patients to seek care from healthcare providers. These conditions are predominantly nontraumatic injuries with a broad differential diagnosis and often without a specific diagnosis despite thorough history and examination. The management of these conditions is often discouraging for patients with continued chronic symptoms despite numerous diagnostic workups and treatment options. Effective communication with respect to the patient's goals is the key to a good outcome. The combination of an accurate diagnosis, an informed, motivated patient and a comprehensive review of the potential treatment options is beneficial for long-term success.

Self-management and self-management support on functional ablement in chronic low back pain

This study examined self-management (SM), self-management support (SMS), and functional ablement in chronic low back pain (CLBP) patients and the role of SM in explaining the relationship of SMS to functional ablement. The pervasiveness of CLBP is alarming in today's health care. Although the literature is beginning to explicate the impact of SM and SMS in other chronic illnesses, these are yet to be clarified in CLBP. The adapted chronic care model guided this study. A nonexperimental, cross-sectional, descriptive design with mediation analysis was used. Through convenience sampling, 110 participants were recruited from two pain centers that used similar multimodal pain management practices. Although the findings showed lack of mediation, it was found that SM and SMS were strongly correlated. Furthermore, overall health was found to be a significant covariate to the functional ablement of CLBP patients. This study assists in advancing knowledge and contributing toward understanding SM, SMS, and functional ablement in CLBP. It is important to engage patients and health care providers in SM and SMS. More exploration is necessary to assess the influences of SM and SMS in CLBP outcomes toward improving the complex care of these patients.

Psychometric properties of the Swedish Rheumatic Disease Empowerment Scale, SWE-RES-23

INTRODUCTION

Empowerment is a central concept in both rheumatology and diabetes care. A Swedish empowerment instrument for patients with rheumatic diseases has not been created before now. The aim of the present study was to determine the psychometric properties of the Swedish Rheumatic Disease Empowerment Scale, SWE-RES-23, such as construct validity, internal consistency reliability, inter-item correlations and discriminant validity.

METHODS

The already existing instrument, the Swedish Diabetes Empowerment Scale (SWE-DES-23), was adapted for use in patients with rheumatic diseases. The adapted instrument was called the SWE-RES-23. In 2009, 260 patients with rheumatic diseases from a rheumatology unit in Sweden completed the instrument. Construct validity was tested by using exploratory factor analysis. Internal consistency reliability was tested by the use of Cronbach's α-coefficient. In order to determine unidimensionality of the empowerment subscales, inter-item correlations were calculated. To establish discriminant validity, an item about self-perceived health from the Short Form (SF) 36 was used in addition to the SWE-RES-23.

RESULTS

The exploratory factor analysis resulted in five factors (empowerment subscales) with eigenvalues >1, explaining 64.1% of the total variance: Goal achievement and overcoming barriers to goal achievement; Self-knowledge; Managing stress; Assessing dissatisfaction and readiness to change; and Support for caring. Cronbach's α values ranged from 0.59 to 0.91, and the value for the total score was 0.92.

CONCLUSION

The results support the possibility of adapting the SWE-DES-23 for use in patients with rheumatic diseases. The SWE-RES-23 shows acceptable psychometric properties, in terms of construct validity and internal consistency reliability. To validate the SWE-RES-23 fully, further studies are needed, with a focus on test-retest correlations.

Engaging consumers living in remote areas of Western Australia in the self-management of back pain: a prospective cohort study

Background

In Western Australia (WA), health policy recommends encouraging the use of active self-management strategies as part of the co-care of consumers with persistent low back pain (LBP). As many areas in WA are geographically isolated and health services are limited, implementing this policy into practice is critical if health outcomes for consumers living in geographically-isolated areas are to be improved.

Methods

In this prospective cohort study, 51 consumers (mean (SD) age 62.3 (±15.1) years) participated in an evidence-based interdisciplinary pain education program (modified Self Training Educative Pain Sessions: mSTEPS) delivered at three geographically isolated WA sites. Self report measures included LBP beliefs and attitudes (Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)), use of active and passive self-management strategies, and health literacy, and global perceived impression of usefulness (GPIU) recorded immediately pre-intervention (n = 51), same day post-intervention (BBQ; GPIU, n = 49) and 3 months post-intervention (n = 25).

Results

At baseline, consumers demonstrated adequate health literacy and elements of positive health behaviours, reflected by the use of more active than passive strategies in self-managing their persistent LBP. Immediately post-intervention, there was strong evidence for improvement in consumers’ general beliefs about LBP as demonstrated by an increase in BBQ scores (baseline [mean (SD): 25.8 (7.6)] to same day post-intervention [28.8 (7.2); P < 0.005], however this improvement was not sustained at 3 months post-intervention. The majority of consumers (86.4%) reported the intervention as very useful [rated on NRS as 7–10].

Conclusions

To sustain improved consumer beliefs regarding LBP and encourage the adoption of more positive health behaviours, additional reinforcement strategies for consumers living in remote areas where service access and skilled workforce are limited are recommended. This study highlights the need for aligning health services and skilled workforce to improve the delivery of co-care for consumers living in geographically isolated areas.

Opioid use in primary care: asking the right questions

Pain is one of the most common reasons that patients seek treatment from health care professionals, often their primary care providers. One tool for treating pain is opioid therapy, and opioid prescriptions have increased dramatically in recent years in the United States. This article will review recent research about opioids that is most relevant to treating chronic pain in the context of a typical primary care practice. It will focus on four key practices that providers can engage in before and during the course of opioid therapy that we believe will enhance the likelihood that opioids, when used, are an effective tool for pain management: avoiding sole reliance on opioids; using adequate opioid doses to address pain; mitigating the risk of opioid misuse by patients; and fostering collaborative relationships for treating complex patients.

Implementation of the veterans health administration national pain management strategy

Since its introduction in 1998, the VHA National Pain Management Strategy has introduced and implemented a series of plans for promoting systems improvements in pain care. We present the milestones of VHA efforts in pain management as reflected by the work of the Strategy. This includes the development of the Strategy and its current structure as well as a review of important initiatives such as "pain as the fifth vital sign" and the stepped care model of pain management.

"They don't want anything to do with you": patient views of primary care management of chronic pain

OBJECTIVE

Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care.

DESIGN

Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish.

PATIENTS

Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts.

RESULTS

Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care.

CONCLUSIONS

Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care.

Barriers and facilitators to chronic pain self-management: a qualitative study of primary care patients with comorbid musculoskeletal pain and depression

OBJECTIVE

To identify barriers and facilitators to self-management of chronic musculoskeletal pain among patients with comorbid pain and depression.

DESIGN

A qualitative study using focus group methodology.

SETTING

Veteran Affairs (VA) and University primary care clinics.

PATIENTS

Recruited after participation in a clinical trial.

INTERVENTION

The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) trial tested an intervention of optimized antidepressant therapy combined with a pain self-management program versus usual care for primary care patients with comorbid chronic pain and depression.

OUTCOME MEASURES

Thematic content analysis from focus group data was used to identify patient-perceived barriers and facilitators to self-management of chronic musculoskeletal pain.

RESULTS

Patients (N = 18) were 27 to 84 years old (M = 54.8), 61% women, 72% white, and 22% black. Barriers to pain self-management included: 1) lack of support from friends and family; 2) limited resources (e.g., transportation, financial); 3) depression; 4) ineffectiveness of pain-relief strategies; 5) time constraints and other life priorities; 6) avoiding activity because of fear of pain exacerbation; 7) lack of tailoring strategies to meet personal needs; 8) not being able to maintain the use of strategies after study completion; 9) physical limitations; and 10) difficult patient-physician interactions. Facilitators to improve pain self-management included 1) encouragement from nurse care managers; 2) improving depression with treatment; 3) supportive family and friends; and 4) providing a menu of different self-management strategies to use.

CONCLUSIONS

Future research is needed to confirm these findings and to design interventions that capitalize on the facilitators identified while at the same time addressing the barriers to pain self-management.