Implementing PROMs in Primary Care and Understanding Chronic Pain

During a session on the final day of PCMH Congress 2019, Sarah Hudson Scholle, MPH, DrPH, and Daren Anderson, MD, addressed issues surrounding the implementation of patient-reported outcome measures (PROM) in the primary care setting. Additionally, they discussed patient characteristics and patterns in both symptoms and function among some who experience chronic pain in primary care.

“Why do we care about chronic pain?” they asked.

According to statistics shared, roughly 100 million Americans are affected by chronic pain, and a majority of these patients are actually seeking care in the primary care setting. Although providers feel that pain care is an important skill, the session presenters explained that many have low confidence in their pain management skills. Oftentimes there are inconsistencies in treatment, follow-up, and continuous assessment. They said that these are the times when opioids are prescribed as first-line treatment, and functional assessment are rarely documented. They also explained, that according to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, prior to beginning opioid therapy. Also, the CDC’s guideline recommends the use of the PEG tool in assessing pain interference to track patient outcomes.

The sessions speakers spoke about the implementation of PROMs in the primary care setting that was in a study conducted called, “Patient-Reported Outcome Measures in Chronic Pain—Feasibility and Usability for Care Planning and Performance Measurement.”

They explained that the steps to implement PROM included, building stakeholder buy-in, setting up workflows and data systems, training the teams, and identifying variations in the implementation and re-training. During the implementation, they created a Planned Care dashboard, which was an electronic health record (EHR) view for medical assistants. The dashboard alerted medical assistants when a patient was due for annual chronic pain screening and follow-up PEG screening if the patient was screened positive for chronic pain. The EHR view for clinicians included stored information that contained information on both chronic pain screening and PEG information.

According to the feasibility findings, the session speakers said they learned the following:

• PEG can alter the initial reason for the visit and extend it;
• Sometimes patients may have trouble responding to the PEG items;
• The use of Language Line adds time needed to complete the PEG; and,
• Translation of the PEG items and clarifications offered to patients are not consistent.

Next, they spoke about understanding the many characteristic of chronic pain in patients. They said that their research questions focused on the following:

• How PEG relates to other pain scales;
• Mental health symptoms among patients with chronic pain;
• How pain changes over time in usual care; and
• How trust and patient activation offers opportunities for intervention.

A survey of a subset of patients was conducted, and it included 701 patients who completed the baseline survey by phone and 388 who completed the 6-month follow-up survey. The researchers collected information on pain functioning, experience with pain, mental health, patient activation, trust in physician, health literacy, and work status.

According to the findings of this study, PEG was found to be consistent with more detailed pain measurement tools. Additionally, there was a high burden in the primary care population that was surveyed. They found that most patients reported severe impairment in functioning, most do not experience change in pain functioning or severity over 6 months in usual primary care, and among patients with chronic pain, depression and anxiety are common. “Interventions should consider mental health symptoms and build on positive trust and engagement,” they said.

The speakers ended their session by noting what’s to come next. They said that they want to analyze both survey and in-clinic PEG results with patient characteristics and treatment factors as well as conduct usability interviews with care teams. Additionally, they want to develop case studies from patients and care team interviews and present them to external primary care providers for feedback on usability. Finally, they said that they want to use findings to inform future interventions to help chronic pain patients.—Julie Gould