Bill H. McCarberg, MD1; Anne Roc, PhD2; Stacey J.P. Ullman, MHS2 1University of California at San Diego, Pain Management, Neighborhood Healthcare, Escondido, California; 2Medscape, LLC, New York, New York

purpose

methods

results

Continuing medical education (CME) can help physicians sharpen their skills at assessing and treating patients with chronic pain and may improve patient outcomes. Traditionally, this has been done through self-assessment and self-directed learning models. However, recent research has shown that physicians may be challenged to accurately assess their own needs.1 Physicians often participate in education that reinforces what they already know and are less likely to identify programs that target their unmet needs. Recent research has also demonstrated that tailored content that matches the needs of learners is often more effective than more generic information.2

To provide tailored content specific to the needs of primary care physicians (PCPs) involved in the management of chronic pain, Medscape, LLC and CE Outcomes, LLC, developed an innovative online learning model called the Personalized Learning Program (http://www.medscape.org/personalized-learning/6003689). This program was designed to address education gaps in pain assessment, functional goal setting and access to multidisciplinary resources, and prescribing appropriate pain therapies, as indicated by Medscape survey data, literature review, and expert opinion.

PCPs completed an online, baseline clinical self-assessment intended to identify their education gaps regarding current evidence-based guidelines and recommendations in the management of chronic pain. The self-assessment included case-based questions that related back to the learning objectives of the Personalized Learning curriculum. Based on the results of their self-assessment, PCPs were provided an individualized learning plan, which included recommendations of up to 6 distinct CME activities that were developed by Medscape, LLC specifically to address the educational gaps, skills, or performance needs of PCPs involved with chronic pain management (Table 1).

At the conclusion of each activity, learners were presented with post-assessment questions which were replicated from the baseline self-assessment and aligned to that activity. Responses to the baseline self-assessment and post-assessment questions were then analyzed. Comparisons were made between the responses of each physician to the baseline self-assessment with the responses of the same physician to the post-assessment questions (that followed each activity), in order to evaluate the change in knowledge and performance decisions associated with the education. The differences between baseline self-assessment and post-assessment responses for each PCP were aggregated as a measure of the impact of the education. Additionally, the PCP learner sample was compared with a demographically similar group of PCPs who did not participate in the education, which served as the control group. Data for the control group were obtained from a random sample of PCPs from a proprietary database who also completed the baseline self-assessment survey but did not complete the CME activities.

conclusion

Tailored education that identifies specific educational needs of physician learners and then guides them to activities and resources that address those needs, rather than reinforcing information they have already mastered, is a unique and innovative approach to online instructional design. These results support recent research on the use of case-based assessments, compared with chart review and standardized patients, as a valid, cost-effective, and noninvasive method to measure a physician’s processes of care.12,13 Such an individualized approach to online CME can result in significant increases in application of knowledge to cases, potentially improving evidence-based practices among PCPs related to the assessment, diagnosis, and treatment of patients with chronic pain.

Assessment Findings

Participants of the Personalized Learning Program (n=277) were 36% more likely to make evidence-based decisions in chronic pain management (actual effect size of 0.55) than matched nonparticipants (Table 2).

Gap 1 Findings:

• Education was successful in helping physicians appropriately use the Brief Pain Inventory to characterize how a patient’s pain impacts their daily function. Participants had significant improvements post-activity (n=113; from 15% at baseline to 46% post-activity, P <.001) and compared with nonparticipants (n=100; 29%, P <.01) in not only selecting an appropriate questionnaire but also in the recognition of the components of the McGill Pain Questionnaire.

• Participants significantly improved post-activity (n=113; from 64% to 76%, P =.02) and were significantly more likely than nonparticipants (n=100; 52%, P <.001) to respond that they would conduct a thorough physical exam for nearly all of their patients prior to developing a treatment plan.

• Post-education participants are significantly more likely than pre-participation (n=75; from 47% to 72%, P =.001) or nonparticipant controls (n=100; 35%, P <.001) to respond that they would utilize a goal-setting form to identify achievable goals prior to determining the treatment regimen (Figure 1).

• Participants were significantly more likely post-activity (n=75; from 41% to 73%, P <.001) and compared with nonparticipants (n=100; 46%, P <.001) to select an open-ended question as the beginning of their evaluation with their patients to fully understand the severity and extent of their chronic pain, rather than asking about family history or prior clinician visits or medication (Figure 2).

Gap 2 Findings:

• Participants significantly improved their recognition of physiologic chronic pain (n=48; from 6% to 21%, P =.05).

• Just over half of post-participants (52%) recognized abnormal illness behavior, such as the refusal to consider any explanations of pain condition and management, as the most significant barrier to developing and communicating a treatment plan for a patient with chronic pain.

• Participants were significantly more likely post-activity (n=31; from 32% to 74%, P =.002) to indicate that a preferred strategy for the management of a patient who presents with chronic pain but has inadequate relief on current opioid therapy would be to establish realistic goals.

Gap 3 Findings:

• Participants were significantly more likely to choose the evidence-based answer post-activity (n=56; from 30% to 84%, P <.001) and vs nonparticipant controls (n=100; 38%, P <.001), with most participants recognizing that nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for neuropathic pain (Figure 3).

• Participants were significantly more likely after the activity (n=56; from 59% to 80%, P =.002) or vs nonparticipants (n=100; 58%, P =.01) to properly categorize the pain of a case patient with non-central nervous system (CNS) tissue damage as nociceptive pain.

• Participants were significantly more likely post-activity (n=194; from 61% to 82%, P <.001) and compared with nonparticipants (n=100; 50%, P <.001) to select the Neuropathic Pain Questionnaire as the most appropriate choice for a patient with neuropathic pain (Figure 4).

• Participants were significantly more likely post-activity (n=194; from 85% to 95%, P <.001) and compared with nonparticipants (n=100; 87%, P =.02) to recognize that treatment plans should include discus-sion of the patient’s functional goals and treatment expectations.

• Participants are significantly more likely post-activity (n=194; from 28% to 69%, P <.001) and compared with nonparticipants (n=100; 47%, P <.001) to select serotonin-norepinephrine reuptake inhibitors (SNRIs) as an appropriate class of antidepressants for treating low back pain (Figure 5).

Successfully Improving the Practice of Chronic Pain Management: An Innovative Personalized Education Approach

Acknowledgments

The Personalized Learning Program was funded through an independent educational grant from Eli Lilly and Company.

Poster layout was provided by Brandon Battersby of Medscape, LLC.

For more information, contact Anne Roc, PhD, Director, Clinical Strategy, Medscape, LLC, aroc@medscape.net.

Disclosures

Bill H. McCarberg, MD, has disclosed the following relevant financial relationships:

Served as an advisor or consultant for: Iroko Pharmaceuticals, LLC; Pfizer Inc; Zogenix, Inc.; Collegium Pharmaceutical; Millennium Laboratories; Mallinckrodt Pharmaceuticals

Owns stock, stock options, or bonds from: Johnson & Johnson Pharmaceutical Research & Develoment, LLC; Protein Design Labs, Inc.; BioSpecifics Technologies Corp.; Nektar Therapeutics

Anne Roc, PhD, has disclosed no relevant financial relationships.

Stacey J.P. Ullman, MHS, has disclosed no relevant financial relationships.

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self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296:1094-1102.

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4. Medscape Education Survey. Neuropathic pain. [.pdf file]. SurveyMonkey.com. Posted September 2006. Accessed August 24, 2011.

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7. Marcus DA. Treatment of nonmalignant chronic pain. Am Fam Physician. 2000;61:1331-1338, 1345-1346.

8. Medscape Education Survey. Pain survey 2009. [.pdf]. SurveyMonkey.com. Posted November 2009. Accessed August 24, 2011.

9. National Fibromyalgia Association (NFA). NFA fibromyalgia survey 2009 [.pdf]. SurveyMonkey.com. Accessed August 24, 2011.

10. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol. 2003;60:1524-1534.

11. Gilron I, Watson CP, Cahill CM, Moulin DE. Neuropathic pain: a practical guide for the clinician. CMAJ. 2006;175:265-275.

12. Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA. 2000;283:1715-1722.

13. Peabody JW, Luck J, Glassman P, et al. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med. 2004;141:771-780.

Data were collected from March 19, 2012 through October 18, 2012. The data were initially examined to ensure the following:

• Non-practicing clinicians were excluded from the analysis;

• Clinicians reporting 0 patients managed in the targeted therapeutic area were excluded from the analysis; and

• Clinicians were excluded from the analysis if they did not meet the target audience criteria for the educational activity.

table 1 Learning Gaps Addressed Through Specific CME Activities in the Personalized Learning Program

Educational Gaps CME Activities

Gap 1: Limited training and ability to use validated instruments for pain assessment and appropriate patient conversations to identify the type, severity, intensity, duration, and underlying pathophysiology of chronic pain conditions3-6

Gap 2: Failure to communicate with patients to set functional goals as a part of the treatment regimen and to provide access to multidisciplinary resources to support their goal attainment7-9

Gap 3: Limited competency in prescribing appropriate pain therapies based on an understanding of the underlying pathophysiology of different pain conditions, mechanisms of action of different treatments, and treatment guidelines9-11

Activity 1. Pain Assessment Tools Made Easy

Activity 2. Pain History and Examination: Talking to Patients About Pain

Activity 3. Probing Functional Domains Affected by Pain: Expert Pain Assessment

Activity 4. Goal Setting, Multidisciplinary Intervention, and Support for Chronic Pain

Activity 5. Noninvasive Combined Treatment Options for Moderate to Severe Chronic Persistent Pain

Activity 6. Success With the Chronic Pain Patient: Case Studies

table 2 Demographics

Primary Care Family medicine Internal medicine General practice Number of patients with chronic pain seen each week 1-9 10-19 20-29 30-39 >40

Practice location Urban Suburban Rural

Present employment Solo practice Group practice Medical school Health maintenance organization Nongovernment hospital Government

Major professional activity Direct patient care activities Administrative activities Medical education Medical research

35%27%15%8%14%

14%33%19%15%19%

29%35%6%3%10%16%

32%55%4%2%6%1%

88%5%5%1%

96%2%1%1%

43%39%18%

48%46%6%

40%48%11%

50%50%0%

Participants(n=277)

Nonparticipants(n=100)

figure 1What is your next step in the management of this patient? (select only 1)

figure 2

Which of the following would you ask first? (select only 1)

figure 3Which of the following classes of pharmacotherapies would you be least likely to recommend for this patient’s persistent Nueropathic pain? (select only 1)

figure 4Which assessment tool would you use for this patient to evaluate her pain? (select only 1)

figure 5Which class of antidepressants has the best evidence-based support for use with this patient? (select only 1)

Utilize a goal-setting form with the patient to identify

achievable goals*

Focus primarily on pain resolution before addressing functional impact

Engage other healthcare providers

to motivate the patient to fully participate in the treatment plan

Engage other healthcare providers

to motivate the patient to fully participate in the treatment plan

Percent of Responders 100%

80%

60%

40%

20%

0%

Post-assessment (n=75) Nonparticipant (n=100)Pre-assessment (n=75)

47%

72%

35%43%

19%

51%

8% 7% 7% 3% 3% 7%

Asterisk (*) indicates the correct answer in Figures 1-5. Pre-assessment vs Post-assessment P =.001; Post-assessment vs Nonparticipant P <.001

Do you have a family history of

this type of pain?

How would you describe your

pain?*

Have you visited other physicians for

this issue?

What pain medications have you taken so far?

Percent of Responders 100%

80%

60%

40%

20%

0%

Post-assessment (n=75) Nonparticipant (n=100)Pre-assessment (n=75)

9% 9% 9%

41%

73%

46%

16%4%

13%

33%

13%

32%

Pre-assessment vs Post-assessment P <.001; Post-assessment vs Nonparticipant P <.001

SNRI* Selective serotonin reuptake inhibitor

(SSRI)

Monoamine oxidase (MAO)

inhibitor

None; antidepressants

would not address his low back pain

Percent of Responders 100%

80%

60%

40%

20%

0%

Post-assessment (n=194) Nonparticipant (n=100)Pre-assessment (n=194)

28%

69%

47%

17%

15%

21%

4% 2% 2%

51%

15%

30%

Pre-assessment vs Post-assessment P <.001; Post-assessment vs Nonparticipant P <.001

Wong-Baker FACES Pain Rating Scale

Patient Health Questionnaire-2

(PHQ-2)

Roland Morris Disability

Questionnare

Neuropathic Pain Questionnaire*

Percent of Responders 100%

80%

60%

40%

20%

0%

Post-assessment (n=194) Nonparticipant (n=100)Pre-assessment (n=194)

28%

9%16%

9% 6%

32%

2% 3% 2%

61%

82%

50%

Pre-assessment vs Post-assessment P <.001; Post-assessment vs Nonparticipant P <.001

Serotonin-norepinephrine

reuptake inhibitor (SNRI)

Tricyclic antidepressant

Nonsteroidal anti-inflammatory drug

(NSAID)*

Anticonvulsants

Percent of Responders 100%

80%

60%

40%

20%

0%

Post-assessment (n=56) Nonparticipant (n=100)Pre-assessment (n=56)

32%

5%14% 16%

7%

24%30%

84%

38%

21%

4%

24%

Pre-assessment vs Post-assessment P <.001; Post-assessment vs Nonparticipant P <.001