HSR&D Home » Research » PMI 03-195 – HSR&D Study
Improving the Treatment of Chronic Pain in Primary Care
Steven K. Dobscha, MD
VA Portland Health Care System, Portland, OR
Funding Period: September 2005 - March 2009
Chronic pain is very common, and associated with substantial impairment and increased healthcare utilization. Implementation of treatment guidelines has been problematic, and chronic pain remains undertreated. Because of the prevalence of chronic pain among veterans, the VHA created a National Pain Management Strategy and adopted pain as the "5th vital sign."
Our primary objective was to determine to what extent a collaborative intervention improves chronic pain-related outcomes (pain-related function, pain severity and depression severity) in a VA primary care setting over six and 12 months. We also investigated to what extent the intervention affected 1) treatment of comorbid depression, 2) adherence of providers to guidelines for chronic pain, 3) patient and provider satisfaction and attitudes related to chronic pain treatment, and 4) incremental benefit (pain disability-free days) and incremental health services costs.
The study was a cluster randomized controlled trial of a collaborative care intervention "Assistance with Pain Treatment" (APT) versus treatment as usual (TAU) at five primary care clinics of one Department of Veterans Affairs Medical Center.
401 patients and 42 primary care clinicians participated. APT included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians and facilitation of specialty care. We randomized clinicians to APT or TAU, and nested patients within clinician intervention status.
Patients were recruited via mailings and advertising flyers; those with chart-documented musculoskeletal pain diagnoses who reported at least moderate pain severity and pain-related function (Chronic Pain Grade [CPG]) lasting at least 12 weeks were invited to participate. Participants completed questionnaires at baseline, 3, 6 and 12 months, with a subset re-assessed at 30 months. Primary outcomes were Roland-Morris Disability scores and CPG pain intensity scale scores over 12 months. Depression was assessed using Patient Health Questionnaire 9 [PHQ-9] scores. Intervention effects on patient outcome variables were tested using intention-to-treat analyses with multilevel models; patient-level covariates of age, sex, baseline depression severity, baseline opioid status (yes/no), and medical morbidity were included. To quantify provider adherence to pain treatment guidelines, we created the Pain Process Measure (PPM), a chart review checklist. Clinicians completed a baseline 23-item survey of attitudes and behaviors related to chronic pain management, job satisfaction, and satisfaction with local pain resources. Patient satisfaction measures included patient-rated global impression of change, global VA health care satisfaction, health-related quality of life, and receipt and rating of effectiveness of VA chronic pain treatment. Pain disability-free days were calculated from Roland-Morris Disability Questionnaire scores. Data on VA treatment costs were obtained from the VA's Decision Support System for all utilization except certain intervention activities that were tracked in a separate study database.
At baseline, back and neck pain diagnoses were present in 67% and 65% of patients, respectively. Mean pain duration was 15 years, and mean Roland-Morris Disability score (range 0 to 24) was 14.7 (sd=4.4). Common comorbidities including major depression (18%), post-traumatic stress disorder (17%), and alcohol misuse (16%). Intervention patients had a mean of 10.6 (SD=4.5; median=10) contacts with the APT team over 12 months. Intervention patients showed greater improvements in pain-related disability (RMDQ: baseline 14.6 vs. 14.5; 12 months 13.3 vs. 14.3, P=.004), pain interference (CPG-Interference baseline 49.3 vs. 48.7; 12 months 44.6 vs. 55.1, P=.03) and pain intensity (CPG-Intensity: baseline 67.4 vs. 66.0; 12 months 63.2 vs. 65.6, P=.01) over 12 months compared to TAU patients. Among patients with baseline depression (PHQ-9 >10), there were greater improvements in depression severity scores (PHQ-9: baseline 14.4 vs. 14.4; 12 months 10.6 vs. 13.2, P=.003) compared to TAU patients over 12 months. Intervention patients also reported significantly greater global impression of change at 6 months (p<.001) and 12 months (p<.001) compared to TAU patients. However, there were no significant differences in EQ5D scores, ratings of global healthcare treatment satisfaction, or ratings of pain treatment effectiveness over 12 months when comparing intervention to TAU patients. Participants in the intervention group experienced an average of 16 additional pain disability-free days over the 12-month follow-up window as compared to the usual care participants; this came at an adjusted cost of $364 per day for a typical participant.
This was the first study to rigorously evaluate a collaborative care approach to chronic pain in the VA. Our primary care-based intervention was significantly more effective than TAU across a variety of outcome measures. Although many of the improvements were modest, they may be especially meaningful because patients in our sample were older, had long-standing pain, multiple medical problems, and reported high baseline rates of disability. Our results add to the growing body of literature suggesting that the collaborative care model is effective in improving clinical outcomes and adherence to treatment guidelines across a variety of chronic conditions.
External Links for this Project
Dimensions for VADimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.
If you have VA-Intranet access, click here for more information vaww.hsrd.research.va.gov/dimensions/
VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project
DRA: Health Systems
DRE: Treatment - Observational
Keywords: Adherence, Depression, Pain
MeSH Terms: none