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

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.

CME Test