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Alter BJ, Anderson NP, Gillman AG, Yin Q, Jeong JH, Wasan AD. Hierarchical clustering by patient-reported pain distribution alone identifies distinct chronic pain subgroups differing by pain intensity, quality, and clinical outcomes. PLoS One 2021; 16:e0254862. [PMID: 34347793 PMCID: PMC8336800 DOI: 10.1371/journal.pone.0254862] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background In clinical practice, the bodily distribution of chronic pain is often used in conjunction with other signs and symptoms to support a diagnosis or treatment plan. For example, the diagnosis of fibromyalgia involves tallying the areas of pain that a patient reports using a drawn body map. It remains unclear whether patterns of pain distribution independently inform aspects of the pain experience and influence patient outcomes. The objective of the current study was to evaluate the clinical relevance of patterns of pain distribution using an algorithmic approach agnostic to diagnosis or patient-reported facets of the pain experience. Methods and findings A large cohort of patients (N = 21,658) completed pain body maps and a multi-dimensional pain assessment. Using hierarchical clustering of patients by body map selection alone, nine distinct subgroups emerged with different patterns of body region selection. Clinician review of cluster body maps recapitulated some clinically-relevant patterns of pain distribution, such as low back pain with radiation below the knee and widespread pain, as well as some unique patterns. Demographic and medical characteristics, pain intensity, pain impact, and neuropathic pain quality all varied significantly across cluster subgroups. Multivariate modeling demonstrated that cluster membership independently predicted pain intensity and neuropathic pain quality. In a subset of patients who completed 3-month follow-up questionnaires (N = 7,138), cluster membership independently predicted the likelihood of improvement in pain, physical function, and a positive overall impression of change related to multidisciplinary pain care. Conclusions This study reports a novel method of grouping patients by pain distribution using an algorithmic approach. Pain distribution subgroup was significantly associated with differences in pain intensity, impact, and clinically relevant outcomes. In the future, algorithmic clustering by pain distribution may be an important facet in chronic pain biosignatures developed for the personalization of pain management.
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Affiliation(s)
- Benedict J. Alter
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| | - Nathan P. Anderson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Andrea G. Gillman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Qing Yin
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ajay D. Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Gillman A, Zhang D, Jarquin S, Karp JF, Jeong JH, Wasan AD. Comparative Effectiveness of Embedded Mental Health Services in Pain Management Clinics vs Standard Care. PAIN MEDICINE 2021; 21:978-991. [PMID: 31994692 DOI: 10.1093/pm/pnz294] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Embedded behavioral medicine services are a common component of multidisciplinary chronic pain treatment programs. However, few studies have studied whether these services are associated with improved treatment outcomes. METHODS Using a retrospective, matched, two-cohort study design, we examined patient-reported outcomes (PROs), including Patient-Reported Outcomes Measurement Information System pain, mental health, and physical function measures, collected at every clinic visit in every patient. Changes from baseline through 12 months were compared in those receiving embedded Behavioral Medicine in addition to usual care to a Standard Care group seen in the same pain practice and weighted via propensity scoring. RESULTS At baseline, Behavioral Medicine patients had worse scores on most pain, mental health, and physical health measures and were more likely to be female, a member of a racial minority, and have lower socioeconomic status. Regardless of having a worse clinical pain syndrome at baseline, at follow-up both Behavioral Medicine (N = 451) and Standard Care patients (N = 8,383) showed significant and comparable improvements in pain intensity, physical function, depression, and sleep disturbance. Behavioral Medicine patients showed significantly greater improvements in their global impressions of change than the Standard Care patients. CONCLUSIONS Despite worse pain and physical and psychological functioning at baseline, Behavioral Medicine patients showed improvements comparable to patients not receiving these services. Further, Behavioral Medicine patients report higher global impressions of change, indicating that embedded mental health services appear to have the additive value of amplifying the benefits of multimodal pain care.
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Affiliation(s)
- Andrea Gillman
- UPMC Pain Medicine, Pittsburgh, Pennsylvania.,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Di Zhang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jordan F Karp
- UPMC Pain Medicine, Pittsburgh, Pennsylvania.,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jong-Hyeon Jeong
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ajay D Wasan
- UPMC Pain Medicine, Pittsburgh, Pennsylvania.,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Bernstein C, Gillman AG, Zhang D, Bartman AE, Jeong JH, Wasan AD. Identifying Predictors of Recommendations for and Participation in Multimodal Nonpharmacological Treatments for Chronic Pain Using Patient-Reported Outcomes and Electronic Medical Records. PAIN MEDICINE 2020; 21:3574-3584. [PMID: 32869082 DOI: 10.1093/pm/pnaa203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE High-quality chronic pain care emphasizes multimodal treatments that include medication and nonpharmacological treatments. But it is not clear which patients will participate in nonpharmacological treatments, such as physical therapy or mental health care, and previous research has shown conflicting evidence. METHODS We used the Patient Outcomes Repository for Treatment (PORT) registry, which combines patient-reported outcomes data with electronic medical records. In this retrospective observational study, we performed two separate multinomial regression analyses with feature selection to identify PORT variables that were predictive of 1) recommendation of a nonpharmacological treatment by the provider and 2) patient participation in nonpharmacological treatments. Two hundred thirty-six patients were recommended (REC) or not recommended (NO REC) a nonpharmacological treatment, and all REC patients were classified as participating (YES) or not participating (NO) in the recommendations. RESULTS Female gender and a diagnosis of Z79 "Opioid drug therapy" were significant positive and negative predictors of nonpharmacological treatment recommendations, respectively. Schedule II opioid use at initial presentation and recommendations for rehabilitation therapy were significant predictors of nonparticipation. CONCLUSIONS Patients using opioids are less likely to be recommended nonpharmacological treatments as part of multimodal chronic pain care and are less likely to participate in nonpharmacological treatments once recommended. Males are also less likely to be recommended nonpharmacological treatments. Patients referred for rehabilitation therapies are less likely to comply with those recommendations. We have identified patients in vulnerable subgroups who may require additional resources and/or encouragement to comply with multimodal chronic pain treatment recommendations.
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Affiliation(s)
- Cheryl Bernstein
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrea G Gillman
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Di Zhang
- Division of Biometrics VII, Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | | | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Ajay D Wasan
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Elwy AR, Wasan AD, Gillman AG, Johnston KL, Dodds N, McFarland C, Greco CM. Using formative evaluation methods to improve clinical implementation efforts: Description and an example. Psychiatry Res 2020; 283:112532. [PMID: 31477261 DOI: 10.1016/j.psychres.2019.112532] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/25/2019] [Accepted: 08/25/2019] [Indexed: 11/27/2022]
Abstract
Formative evaluation, a rigorous assessment process to identify potential and actual influences on the implementation process, is a necessary first step prior to launching any implementation effort. Without formative evaluation, intervention studies may fail to translate into meaningful patient care or public health outcomes or across different contexts. Formative evaluation usually consists of qualitative methods, but may involve quantitative or mixed methods. A unique aspect of formative evaluation is that data are shared with the implementation team during the study in order to adapt and improve the process of implementation during the course of the study or improvement activity. In implementation science, and specifically within formative evaluation, it is imperative that a theory or conceptual model or framework guide the selection of the various individual, organizational or contextual factors to be assessed. Data from these theory-based constructs can translate into the development and specification of implementation strategies to support the uptake of the intervention. In this article, we describe different types of formative evaluations (developmental, implementation-focused, progress-focused, and interpretive), and then present a formative evaluation case study from a real-world implementation study within several academic pain clinics, guided by the Theory of Diffusion of Innovation.
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Affiliation(s)
- A Rani Elwy
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road (Mailstop 152), Bedford, MA 01730, USA; Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Box G-BH, Providence, RI, USA.
| | - Ajay D Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh School of Medicine, UPMC Pain Medicine, 5750 Centre Avenue, Suite 400, Pittsburgh, PA 15206, USA
| | - Andrea G Gillman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Kelly L Johnston
- Department of Psychiatry, University of Pittsburgh Medical Center, 100 North Bellefield, Rm 770, Pittsburgh, PA 15213, USA
| | - Nathan Dodds
- Department of Psychiatry, University of Pittsburgh Medical Center, 100 North Bellefield, Rm 770, Pittsburgh, PA 15213, USA
| | - Christine McFarland
- Department of Psychiatry, University of Pittsburgh School of Medicine, UPMC Center for Integrative Medicine, 580 S. Aiken Avenue, Suite 310, Pittsburgh, PA 15232, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh School of Medicine, UPMC Center for Integrative Medicine, 580 S. Aiken Avenue, Suite 310, Pittsburgh, PA 15232, USA
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Erdek MA. Pay-for-Performance Reimbursement for Clinicians: Common Sense or a Wolf in Sheep's Clothing? PAIN MEDICINE 2019; 19:2106-2108. [PMID: 30321393 DOI: 10.1093/pm/pny168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Michael A Erdek
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, and Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Hundley HE, Hudson ME, Wasan AD, Emerick TD. Chronic pain clinic efficiency analysis: optimization through use of the Gantt diagram and visit diagnoses. J Pain Res 2018; 12:1-8. [PMID: 30588074 PMCID: PMC6301303 DOI: 10.2147/jpr.s173345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study is to identify scheduling inefficiencies and to develop a personalized schedule based on diagnosis, service time (face-to-face time between the patient and the provider), and patient wait time using a Gantt diagram in a chronic pain clinic. Design This is an observational prospective cohort quality improvement (QI) study. Setting This study was carried out at a single outpatient multidisciplinary pain management clinic in a university teaching hospital. Subjects New and established chronic pain patients at the University of Pittsburgh Medical Center (UPMC) Montefiore Chronic Pain Clinic were recruited for this study. Methods Time tracking data for each phase of clinic visit and pain-related diagnoses were collected from 81 patients on 5 clinic days in March 2016 for patient flow analysis. Results A Gantt diagram was created using Microsoft Excel® software. Areas of overbooking and underbooking were identified. Median service times (minutes) differed dramatically based on the diagnosis and were highest for facial pain (23 [IQR, 15–31]) and chronic abdominal and/or pelvic pain (21.5 [IQR, 16–27]) and lowest for myalgia. Abdominal and/or pelvic pain and facial pain median service times consistently exceeded the 15-minute allocation for return visits. Conclusion Schedule efficiency analysis using the Gantt diagram identified trends of overbooking and underbooking and inefficiencies in examination room utilization. A 15-minute appointment for all return patients is unrealistic due to variation of service times for some diagnoses. Scheduling appointments based on the diagnosis is an innovative approach that may reduce scheduling inefficiencies and improve patient satisfaction and the overall quality of care. To the best of our knowledge, this type of scheduling diagram has not been used in a chronic pain clinic.
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Affiliation(s)
- Hayden E Hundley
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark E Hudson
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University of Pittsburgh Physicians, Pittsburgh, PA, USA,
| | - Ajay D Wasan
- University of Pittsburgh Physicians, Pittsburgh, PA, USA, .,Division of Chronic Pain, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,
| | - Trent D Emerick
- University of Pittsburgh Physicians, Pittsburgh, PA, USA, .,Division of Chronic Pain, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,
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