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Does Poor Pain Management Prevail in Primary Care?

  • Authors: News Author: Troy Brown, RN
    CME Author: Charles P. Vega, MD, FAAFP
  • CME Released: 11/14/2013
  • Valid for credit through: 11/14/2014, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, pain management specialists, and other specialists who care for patients with pain.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Evaluate the most significant risk factors for poor pain management in a previous study.
  2. Evaluate variables that affect the management of painful conditions.


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  • Troy Brown, RN

    Troy Brown, RN, is a freelance writer for Medscape.


    Disclosure: Troy Brown, RN, has disclosed no relevant financial relationships.


  • Amy Nadel


    Disclosure: Amy Nadel has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P. Vega, MD, FAAFP

    Associate Professor and Residency Director, Department of Family Medicine, University of California-Irvine, Irvine


    Disclosure: Charles P. Vega, MD, FAAFP, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Yullee C. Chui

    Program Manager, Medscape, LLC


    Disclosure: Yullee C. Chui has disclosed no relevant financial relationships.

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Does Poor Pain Management Prevail in Primary Care?

Authors: News Author: Troy Brown, RN CME Author: Charles P. Vega, MD, FAAFPFaculty and Disclosures

CME Released: 11/14/2013

Valid for credit through: 11/14/2014, 11:59 PM EST


Clinical Context

Pain is a critical yet often misunderstood symptom in clinical offices, and there is substantial variability in how individual physicians approach the patient with pain. Green and Hart-Johnson used a validated tool to measure the adequacy of pain medication among a cohort of adults with chronic pain, and their results were published in the August 2010 issue of the Journal of Pain. They found that most patients received adequate pain management in primary care. Although black vs white patients received fewer pain medications, black race was not significantly associated with worse pain management in multivariate analyses. However, women consistently received worse pain management than men. This difference was most pronounced among young women and men.

The current study by Maserejian and colleagues uses a unique study design to evaluate how multiple variables affect clinicians' approach to patients in pain.

Study Synopsis and Perspective

Fewer than one third of physicians are following current recommendations and giving exercise advice to patients with osteoarthritis or sciatica, according to a balanced factorial experiment among 192 primary care physicians in the United States.

Nancy N. Maserejian, ScD, a senior research scientist and associate director of epidemiology at New England Research Institutes, Inc, Watertown, Massachusetts, and colleagues report their findings in an article published online October 8 in Arthritis Care & Research.

"[T]his experiment found variation in the quality of musculoskeletal pain management decisions, particularly to provide exercise and other lifestyle advice, associated with physicians' years in practice and organizational cultural values. Generally, newer physicians had greater adherence to current recommendations," the authors write.

The physicians watched 2 videos of different patients (actors) who presented with pain from either undiagnosed sciatica symptoms or diagnosed knee osteoarthritis and completed short interviews after regarding what their recommendations would be to the patient.

Unconfounded effects were estimated by analyzing systematic variations in patient gender, socioeconomic status, race, and physician gender and experience (< 20 vs ≥ 20 years in practice).

Associations between patient or provider attributes and clinical decisions were evaluated using variance analysis.

Current recommendations of the American College of Rheumatology, American Pain Society, and clinical expert consensus were used to judge the quality of decisions.

Less than one third of physicians reported that they would give exercise advice (30.2% for osteoarthritis, 32.8% for sciatica). Physicians in practice for fewer years were more likely to give advice on lifestyle changes (P = .01), especially regarding exercise habits (39.6% of newer physicians vs 26.0% of more experienced physicians for sciatica or 20.8% of more experienced physicians for osteoarthritis).

Newer physicians were also more likely to prescribe nonsteroidal anti-inflammatory drugs for pain relief (68.8% vs 52.1% [P = .01] for the patient with sciatica; 80.2% vs 67.7% [P = .02] for the patient with osteoarthritis).

Newer physicians were less likely to order tests (sciatica, mean 1.9 vs 2.5 tests [P = .01]; osteoarthritis, 2.4 vs 2.9 tests [P = .07]), especially basic laboratory tests (eg, complete blood count or metabolic panel, 9.4% vs 21.9%; P = .02) and urinalysis (4.2% vs 16.7%; P = .003), particularly for sciatica. For the patient with osteoarthritis only, radiographs were more often ordered by newer physicians (85.4% vs 69.8%).

Test ordering decreased as the organization's emphasis on business or profits increased.

Patient factors and gender of the physician had inconsistent effects on the evaluation and treatment of pain.

"Overall, the observed variations in decision-making were still largely unexplained even after accounting for all the patient, provider, and organizational variables that were statistically significant in the multivariable models," the authors write. "Methods to more effectively disseminate current recommendations for diagnosis and management of pain conditions should be developed and tested to improve the quality of care for these common clinical problems," they conclude.

This article received financial support from an Award from the National Institute of Arthritis and Musculoskeletal and Skin Disorders at the National Institutes of Health. One coauthor has received research support from CVS-Caremark for studies of medication adherence. The other authors have disclosed no relevant financial relationships.

Arthritis Care Res. Published online October 8, 2013. Abstract

Study Highlights

  • The study was designed as a balanced factorial experiment, which can analyze multiple variables for a desired outcome. Researchers were specifically interested in how the following patient variables affected management: gender of the patient, race/ethnicity, socioeconomic status, and request for a particular medication. Researchers also included gender of the physician and years of experience in patient care as variables.
  • All physicians participating in the study were either family medicine specialists or internists who spent at least half of their time in clinical care.
  • Physicians viewed 2 taped patient vignettes that included multiple versions to assess the researchers' desired patient variables. One vignette featured a case of sciatica, and another featured osteoarthritis of the knee.
  • The primary study outcomes were clinicians' decisions regarding testing and treatment of these patients.
  • 192 physicians participated in the study. Their average time in their current practice was 10.8 years. The group was nearly evenly split between family and internal medicine. 55.2% of physicians were white, 24.5% were Asian, 7.3% were black, and 5.7% were Hispanic.
  • 95% of physicians believed that the patient vignettes reflected real cases that they might see in their practices.
  • Physician gender, race/ethnicity, specialty, or career satisfaction did not affect patient management decisions.
  • In contrast, physicians with less experience were more likely to follow clinical guidelines in emphasizing lifestyle factors to reduce symptoms, and they were more likely to recommend physical therapy.
  • Practices with an emphasis on quality of care featured higher percentages of physicians offering exercise advice for osteoarthritis.
  • Newer physicians were also more likely than older physicians to prescribe nonsteroidal anti-inflammatory drugs, but they were less likely to order ancillary testing, particularly blood and urine tests.
  • The researchers note that magnetic resonance imaging (MRI) would be considered inappropriate for the patients represented in both vignettes. Yet 33.9% of physicians would have ordered an MRI for the patient with sciatica, and 13.5% would order an MRI for the patient with known knee osteoarthritis.
  • Among patient factors, higher socioeconomic status was associated with a greater proportion of prescriptions for narcotics, whereas lower socioeconomic status was associated with greater use of nonsteroidal anti-inflammatory drugs.
  • The only other significant patient factor associated with a difference in management was Hispanic ethnicity, which was associated with lower rates of laboratory testing or imaging vs non-Hispanic white or black race.

Clinical Implications

  • A previous study by Green and Hart-Johnson found that female gender was associated with the most substantial negative disparity in pain management among adults in primary care.
  • In the current study by Maserejian and colleagues, the most important physician or patient factor associated with a difference in the management of painful conditions was the years of experience of physicians in practice.

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