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
Co-Authors
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Richard Street, Jr., PhD


Jane Bolin, PhD, JD, RN


Texas A&M University
Texas A&M Health Science Center
Xiaoming Bao, MS

Texas A&M Health Science Center
2
Introduction
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Chronic pain is common among older
adults
PCPs deliver most pain management
PCPs serve as “Advanced Medical
Home” for elderly patients
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Cognitive labor
Emotional labor
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Guideline: Assessment
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Assessment and documentation of
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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
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Develop a written plan of care
Pharmacological management
Non-pharmacologic strategies
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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
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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 undertreatment of pain (Loewenstein
2003)
Disparities (Bernabei et al. 1998)
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Current Study Questions
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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
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Videotapes
 385 patient visits
 35 primary care physicians
 3 types of practice settings
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AMC, MCG, ICS
1999-2000
 >2500 topics
 >100 hours of recording
Patient survey
Physician survey
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Mixed Method Approach
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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
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Sequential Topic Mapping
Pt
MD
0.0
0.2
1.1
0.5
7.4
1.6
2.0
0.3
0.9
0.1
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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
Other
52 (15)
28 (7)
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Physician Sample
Age
Male
49 (range: 32-82)
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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Patient-Physician Dyads
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Age matching
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14% age ≤10 years of each
other
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Gender Concordance
Female
MD
Male
MD
Female
Pt
18
49
Male Pt
4
29
14
Racial Concordance
White
PT
Non-white
PT
White
MD
Non-White
MD
79
2
9
10
15
Visits
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# of topics in a visit:
Mean = 6.5
 Median=6, Min=1, Max=12
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Average length of visit
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17.4 min
Median length of visit
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15.7 min
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Descriptive Statistics
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How often
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48% at least one discussion of pain
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How long
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138 contained one pain topic
38 had two pain topics, and
7 had 3 pain topics
3.37 min (6 sec - 15.4 min)
Patient initiation
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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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Empathy gap?
Emotional, cognitive labor?
Conclusions
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Sociodemographics and time
constraints mattered more than
pain
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Concordance=> better
quality?
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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
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Implications
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Standards of care
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Primary care as “advanced
medical home”
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what should happen during the
discussion
How to make it more functional
System interventions
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“It’s the System!”
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Are You Ready?
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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?
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