Painful Facts about Pain Management
Inside Primary Care
Ming Tai-Seale, PhD, MPHTexas A&M Health Science Center
Funding sources: NIMH MH01935, NIA AG15737
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Co-Authors
Richard Street, Jr., PhD Texas A&M University
Jane Bolin, PhD, JD, RN Texas A&M Health Science Center
Xiaoming Bao, MS Texas A&M Health Science Center
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Introduction
Chronic pain is common among older adults
PCPs deliver most pain management PCPs serve as “Advanced Medical
Home” for elderly patients Cognitive labor Emotional labor
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Guideline: Assessment
Assessment and documentation of
Pain location Intensity (scale, happy/sad face…) Onset Duration Variation Rhythms and Manner of expressing
(www.Guidelines.gov)
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Guideline on Treatment
Develop a written plan of care Pharmacological management Non-pharmacologic strategies
physical activity programs acupuncture patient education, and cognitive behavioral therapy
Follow-up assessments, using same scales and measures
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Realities in Practice
Time is scarce in primary care Competing demands (Tai-Seale et
al 2006) Pressure to be “productive” and
have short visits Hot-cold empathy gap and under-
treatment of pain (Loewenstein 2003)
Disparities (Bernabei et al. 1998)
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Current Study Questions
What determines the probability that pain would be discussed?
What happens when pain is discussed?How much time is spent on
addressing pain?What determines the length of time
allocated to pain management?
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Data
Videotapes 385 patient visits 35 primary care physicians 3 types of practice settings
AMC, MCG, ICS 1999-2000 >2500 topics >100 hours of recording
Patient survey Physician survey
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Mixed Method Approach
QualitativeWhat happens in a visitWas there a discussion on pain
QuantitativeHow often does pain topic occur How much time is allocated to
discussing pain
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Patient Sample
Patient Age N (%)
65-75 197 (54)
75-85 132 (36)
>85 37 (10)
Female 243 (65)
White 298 (79)
African American 52 (15)
Other 28 (7)
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Physician Sample
Age 49 (range: 32-82)
Male 27 (77%)
White 26 (83%)
Academic Med Ctr 10 (29%)
Managed Care Org 21 (60%)
Inner City Solo (AA) 4 (11%)
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Visits
# of topics in a visit: Mean = 6.5 Median=6, Min=1, Max=12
Average length of visit 17.4 min
Median length of visit15.7 min
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Descriptive Statistics
How often 48% at least one discussion of pain
138 contained one pain topic 38 had two pain topics, and 7 had 3 pain topics
How long 3.37 min (6 sec - 15.4 min)
Patient initiation 55%
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Prob of Having a Pain Topic
O.R. P-value
Different gender 1.64 <.05
SF36 bodily pain .97 <.10
Controlled for: education, MD in family practice, MD years in practice, years of patient-MD relationship, presence of companion, racial concordance, age concordance.
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Length of Discussion
Duration Analysis H.R. %
2nd – 3rd topic 1.7* -32%
4th – 6th topic 2.2** -44%
≥7th topic 4.7** -68%
≥ high school education 0.7* 25%
Racially discordant 1.5* -24%
Controlled for covariates, *: p<0.05, **: p<0.01
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Exemplar - Assessment
Stressed out grandma, African American, SF36 pain=25
Older physician, inner city ffs solo,
D: The knees bothering you? Can you expose your knees for me? (examines range of motion) Let's see, does it hurt you in here?
P: No.…
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Exemplar - Treatment
D: Well let me tell you now, you know how bad your knees are bothering you. Use that as an indicator as to how important it is that you get the weight off them. Understand? Don't want to be falling down, hobbling like this when all you have to do is lose about 50 pounds and you'll move around much better. I'm gonna give you some tablets to take for that, you hear?
…P: What did you think about the Vioxx?
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Gender concordance was the only factor in determining the probability of having a pain discussion
Length of discussion on pain was determined by time constraints and demographics
Patients with better education had longer discussions about pain
Racial concordance increases the length of discussion, but does not guarantee empathy
Concordance=> better quality?
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Implications
Standards of care what should happen during the
discussion Primary care as “advanced
medical home” How to make it more functional
System interventions “It’s the System!”
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Are You Ready?
50 million patients in the U.S. currently enduring chronic pain and
Another 25 million suffering from acute pain
Are you, your colleagues, and employers ready for the WAVE of patients with pain projected to flood the healthcare system when 1 in 5 individuals reach age 65 or older in the year 2011?