The influence of decision aids among patients with chronic pain Joseph M. Bumgarner, MD Internal Medicine, PGY-1 ACC Noon Conference December 8, 2010

Background • Pain is the most commonly reported symptom in the Primary Care setting with 57% of American adults suffering from chronic or recurrent pain. • Chronic pain is also costly with an estimated $100 billion per year spent on health care and lost worker productivity. • Pain-related problems account for up to 80 percent of visits to physicians; the price tag for back pain alone is estimated to be $30 to 50 billion annually in the United States. • Other estimates, taking into account lost wages and social support, suggest that the cost to taxpayers of chronic pain is between $15,000 and $24,000 per patient per year. • Despite organizational efforts and campaigns, such as “Pain as the 5th Vital Sign,” to raise awareness of pain as a public health problem, chronic pain is still undertreated.

The plight of Pain Management Lack of Training

Communi -cation

Time

Primary Care Physician Lack of Consensus on Optimal Tx

Patient Expectations

Stigma of Opiods

Patient Centered Care 1. Empathy

2. Patient Education and Empowerment 3. Treating Patients as Partners in their Healthcare.

Shared Decision Making

Research on patient centered care demonstrates that patients involved in shared decision making: • Change doctors less

• Are more satisfied with their physician • Demonstrate better emotional health • Have a decreased need for unnecessary diagnostic tests and referrals

Shared Decision Making The Primary Care Physician’s Perspective: Findings from a National Survey of Physicians

• 402 PCPs interviewed nationwide. • December 15-22, 2008 using Harris Interactive’s Physician Panel built from the AMA’s database of physicians. • Panelists recruited by mail to complete a 15min online survey. • $50 incentive for completion of the survey. • Conducted by Lake Research Partners.

Shared Decision Making The Primary Care Physician’s Perspective: Findings from a National Survey of Physicians RESULTS •

of Physicians say SDM represents a positive process.

•

Majority of Physicians (81%)most value SDM around changing lifestyle behaviors.

•

50% of Physicians perceive the benefit of SDM to be better management of chronic conditions and medications.

•

93%

Nearly All show willingness to try decision aids that met Physicians’ standards

BARRIERS

• “Not enough time with patients for detailed discussion” tops list of barriers to SDM. • Inadequate reimbursement rates and shrinking office visit times are top concerns for physicians. 78% say recent changes in reimbursements have decreased the amount of time they spend with patients. • 87% of Physicians say that “most” or “some” of their patients are under or misinformed • 69% of Physicians report that patients prefer to rely on physician information alone.

Decision Aids • Developed to prepare patients to discuss “close call” decisions with their healthcare practitioner.

• Decision aids approved by national medical associations are much more likely to facilitate trust and comfort among Physicians. • The International Patient Decision Aids Standards (IPDAS) Collaboration has developed criteria to standardize these aids. • Evidenced-Based, Detailed, Specific, and Personalized

• In 2006, decision aids from large scale producers were accessed over 8 million times by patients and practitioners.

Decision Aids Cochrane Review of Available Decision Aid Trials Published in 2009 -25 RCTs included between 1996 and 2006 -Compared decision aid use to usual care, no intervention, or alternative interventions.

-Wide range of decision aids evaluated from breast cancer screening to prenatal visit information to prostate screening to dental procedures.

Conclusions: Decision aids performed better than usual care interventions in terms of: a) greater knowledge b) lower decisional conflict related to feeling uninformed c) lower decisional conflict related to feeling unclear about personal values d) reduced the proportion of people who were passive in decision making e) reduced proportion of people who remained undecided post-intervention

Shared Decision making video Other Video Topics: -Benign Prostatic Hyperplasia -Colon Cancer -Diabetes -Depression -Hip Osteoarthritis -Knee Osteoarthritis -Menopause -Weight Loss Surgery

Clinic support website

Clinic Support Website

Our Project Questions: 1. Does viewing the chronic pain decision aid video influence intent to discuss non-pharmacologic treatment options for chronic pain with the patient’s healthcare practitioner? 2. Does viewing the decision aid result in improved pain or psychosocial measures at one month follow-up?

Methods Date Range: 1/4/2010 through 10/25/2010

Inclusion Criteria: 1.

Living patients enrolled in the UNC IM Pain Program

2.

A follow up visit in the UNC IM Pain Program

3.

Not discharged from the pain program for violating pain contract

4.

Patients who viewed the pain decision aid

Methods Data Collection: 1. Performed WebCIS chart review of 127 patients who met inclusion criteria for pain scores (including lowest, average, highest, and current) and psychosocial measures (concentration, energy, sleep, appetite, and mood) at baseline and 1 month follow up. 2. Compiled patient report data of intent to use non-pharmacologic therapy for chronic pain before and after DVD use from pre and post DVD survey in the above patients.

Pre-DVD Survey

POST-DVD Survey

Results N = 70

Pre Decision Aid Survey Responses 0.80 0.80 0.70

0.60 0.56

0.60 0.50

0.53

0.41

0.40

Pre-Video Yes

0.39

0.40

Pre-Video No No Response

0.30 0.20

0.10

0.19 0.09 0.01

0.00

0.03

0.00 Pain Medicine

Relaxation Techniques

Getting Enough Sleep

Physical Activity

Intent to Discuss NonPharmacologic Treatments Pain Medicine 0.80 0.80

Relaxation Techniques 0.70

0.60 0.61

0.77 0.60

0.70 0.50

0.60

0.40

0.50

0.40

0.40

0.30

0.30 0.20 0.10 0.00

0.21

0.19

0.20 0.10

0.00

0.23

0.01

0.06 0.00

0.00

Intent to Discuss NonPharmacologic Treatments Getting Enough Sleep

Physical Activity

0.60 0.60

0.60

0.50

0.41

0.40 0.30

0.23 0.20

0.39 0.27

0.30 0.20

0.09

0.09

0.10

0.01

0.03 0.00

0.53

0.50

0.40

0.10

0.69

0.70

0.56

0.00

Who should make decisions “Who do you think should make the decisions about how to manage your chronic pain?” 0.80

0.80

0.74

0.70 0.60 0.50 0.40

Pre Video N= 69

Post Video N= 54

0.30 0.20 0.10

0.13 0.01 0.02

0.06 0.06

0.09

0.06

0.04

0.00

Totally You

You > Doctor

Both You and Your Doctor

Doctor > You

Totally Your Doctor

Psychosocial Measures N = 70

Average change in patients who completed the video Average change in patients who did not complete the video p-Value 95% CI

Concentration

Energy

Appetite

Sleep

Mood

-0.30

-0.16

-0.36

-0.09

-0.23

-0.30 0.7964 -0.50 to 0.38

-0.20 0.4987 -0.22 to 0.45

-0.37 0.6186 -0.41 to 0.69

0.20 0.40 0.175 0.0234 -1.23 to 0.23 -1.04 to -0.08

•Negative Scores Imply Benefit •Data Suggests Small but Significant Improvement in Energy Scores •No Significant Changes found in any other Psychosocial Measures

Pain Scores N = 70 Worst Pain

Least Pain

Average change in patients who completed the video 0.37 0.67 Average change in patients who did not complete the video -0.20 0.73 p-Value 0.1599 0.9145 95% CI -0.23 to 1.37 -1.20 to 1.08

Average Pain

Current Pain

Days Between Follow-Up

1.11

0.14

28.50

0.07 0.0193 0.17 to 1.92

0.87 0.129 -1.66 to 0.21

27.37 0.8538 -11.87 to 14.31

•Positive Scores Imply Benefit •Data Suggests Significant Improvement in Average Pain Scores •No Significant Changes found in any other Pain Measures

•No Significant Change in Days Between Follow-Up

Conclusions 127 patients reviewed with a final inclusion population of 70 patients. Average follow-up interval was 28.5 days. Question 1: Does viewing the chronic pain decision aid video influence intent to discuss non-pharmacologic treatment options? for chronic pain with the patient’s healthcare practitioner? Patients appear to gain intent to discuss better sleep and physical activity. Question 2: Does viewing the decision aid result in improved pain or psychosocial measures? Patients trend toward improvement in most measures, significantly so in energy and average pain scores.

Future Directions • Complete further statistical analysis of available data to identify relationships between intent to use nonpharmacological measures and gender, race, and education level. • Analyze data with respect to medication variables.

• Evaluate specific education points obtained by the patient while watching the chronic pain decision aid. • Improve availability and use of the decision aid series and measure outcomes with other decision aid topics.

References •

Frantsve, Lisa and Robert Kerns. Patient-Provider Interactions in the Management of Chronic Pain: Current Findings within the Context of Shared Medical Decision Making.Pain Medicine 2007; Vol 8: 25-35.

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Informing and Involving Patients in Medical Decisions: The Primary Care Physicians’ Perspective Lake Research Partners on behalf of the Foundation for Informed Medical Decision-Making. http://www.informedmedicaldecisions.org/pdfs/WhitePaperExecutive Summary.pdf. Accessed December 4, 2010.

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Latham, J, Davis, BD. The socioeconomic impact of chronic pain. Disabil Rehabil 1994; 16:39.

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Matthias, Marianne, Amy Parpart, Kathryn Nyland, Monica Huffman, Dawana Stubbs, Christy Sargant, and Mtthew Blair. The Patient-Provider Relationship in Chronic Pain Care: Provider’s Perspective. Pain Medicine 2010; Vol 11: 1688-1697.

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O’Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, Fiset V, HolmesRovner M, Khangura S, Llewellyn-Thomas H, Rovner D. Decision aids for people facing health treatment or screening decisions. Cochrane Database ofSystematic Reviews 2009, Issue 3. Art. No.: CD001431. DOI: 10.1002/14651858.CD001431.pub2.

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Schmitt, P. Rehabilitation of chronic pain: A multi-disciplinary approach. J Rehabil 1985; 51:72.

Thank you! • Dr. Carmen Lewis • Dr. Tom Miller

• Dr. Tim Ives • Leslie Stewart • Cole Andrew • Kim Young-Wright • Shaun McDonald

Thanks for your attention! Questions? Comments?