Painful Facts about Pain Management Inside Primary Care Ming Tai-Seale, PhD, MPH Texas A&M Health Science Center Funding sources: NIMH MH01935, NIA AG15737

2 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

3 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

4 Guideline: Assessment Assessment and documentation of Pain location Intensity (scale, happy/sad face…) Onset Duration Variation Rhythms and Manner of expressing (

5 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

6 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)

7 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?

8 Data Videotapes 385 patient visits 35 primary care physicians 3 types of practice settings AMC, MCG, ICS >2500 topics >100 hours of recording Patient survey Physician survey

9 Mixed Method Approach Qualitative What happens in a visit Was there a discussion on pain Quantitative How often does pain topic occur How much time is allocated to discussing pain

10 Sequential Topic Mapping PtMD

11 Patient Sample Patient AgeN (%) (54) (36) >8537 (10) Female243 (65) White298 (79) African American52 (15) Other28 (7)

12 Physician Sample Age49 (range: 32-82) Male27 (77%) White26 (83%) Academic Med Ctr10 (29%) Managed Care Org21 (60%) Inner City Solo (AA) 4 (11%)

13 Patient-Physician Dyads Age matching 14% age ≤10 years of each other

14 Gender Concordance Female MD Male MD Female Pt 1849 Male Pt429

15 Racial Concordance White MD Non-White MD White PT 792 Non-white PT 910

16 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 visit 15.7 min

17 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 min) Patient initiation 55%

18 Prob of Having a Pain Topic O.R.P-value Different gender1.64<.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.

19 Length of Discussion Duration AnalysisH.R.% 2 nd – 3 rd topic1.7*-32% 4 th – 6 th topic2.2**-44% ≥7 th topic4.7**-68% ≥ high school education0.7*25% Racially discordant1.5*-24% Controlled for covariates, *: p<0.05, **: p<0.01

20 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. …

21 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?

Empathy gap? Emotional, cognitive labor?

23 Conclusions Sociodemographics and time constraints mattered more than pain

24 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?

25 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!”

26 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?