Browsing by Subject "Chronic Pain"
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Item Computer-Administered Patient Reported Outcomes (PRO) and Psychiatric Screening in Outpatient Pain Patients: Effect of a Point-of-Care Biopsychosocial Patient Health Report on Treatment Outcomes(2012-08-13) Swanholm, Eric Neal; Gatchel, Robert J.Rationale: Chronic pain is a widespread health problem that carries steep costs for both individuals and society. Pain-related complaints represent one of the most common presenting symptoms across ambulatory care settings. Individuals with chronic pain often have comorbid psychiatric symptoms and/or psychosocial dysfunction. Given the related impact on treatment and health-care costs, tracking psychiatric and psychosocial outcomes is beneficial for chronic pain patients, their health care providers, and service providers. Outcome-tracking interventions that could positively affect treatment outcomes hold potential benefits for patient care. Purpose: The purpose of the present study was to examine the effects of the regular collection and results feedback prior to the point-of-care on multiple patient-reported outcome (PRO) domains in outpatient pain patients. Maximizing ecological validity and non-disruption of clinic flow were given significant focus in the study design and process. Patients and Methods: This study used repeated measures and was conducted in an outpatient pain management and interdisciplinary treatment clinic (2 anesthesiologists, 1 psychiatrist, 1 psychologist, 1 counselor, 1 physical therapist). A total of 69 pain patients were randomly assigned to one of two protocol-based PRO feedback intervention groups (separate feedback to both patients and providers [Dual Feedback]; Provider-Only Feedback) or a non-intervention group (Chart-Review Only). Assessments were completed prior to the point-of-care; feedback for intervention groups was based upon a real-time, automated report generated from their PRO data. Data were gathered on touch-screen tablet-pc’s using multiple computer-adaptive-tests from the NIH-sponsored Patient Reported Outcomes Measurement Information Systems (PROMIS) Assessment Center platform; outcome domains included pain-related functioning (Pain Disability Questionnaire [PDQ]; VAS pain rating; PROMIS Physical Functioning, Pain Behavior, and Pain Interference), psychological symptoms and psychosocial variables (PROMIS Depression, Anxiety, Sleep-Related Impairment, Fatigue, Social Functioning; hypomania history screen; Pain Medication Questionnaire [PMQ; opioid misuse risk]), global HRQoL (PROMIS Mental and Physical Health domains), treatment alliance (Working Alliance Inventory [WAI]; ratings from both patients and providers]), and illness perception and optimism (Brief Illness Perception Questionnaire [BIPQ]; Life Orientation Test- Revised). Performance-based data (walking time, grip strength, range-of-motion/flexibility) were collected by the physical therapist for study patients whose treatment included a PT component (e.g. interdisciplinary pain program, individual services). Significant covariates were identified and incorporated into the primary analyses. Primary outcomes were the individual measures within each outcome domain. Analyses utilized mixed-effects modeling with random coefficients and multiple regression in comparisons of all three study groups. Secondary analysis included tabulation of completion time and comparisons between a Combined Feedback group (both intervention groups) and Chart-Review Only. Results: Significant covariates included treatment type, history of psychiatric diagnosis, and a biological family history of psychiatric diagnosis. Comparing Dual Feedback vs. Chart Review Only, patients in the Dual Feedback intervention had significantly better outcomes over time for a number of domain outcomes; specifically, in pain-related functioning/symptoms (PDQ [P = .003]; PROMIS Pain Interference [P = .023]; VAS pain [P = .03]), psychological and psychosocial variables (PROMIS Anger [P = .001]; PROMIS Anxiety [P = .012]; PROMIS Depression [P = .029]; PROMIS Sleep-Related Impairment [P = .001]; PROMIS Social Functioning – Satisfaction with Discretionary Social Activities [P = .047]), PROMIS Global HrQOL (Mental Health [P = .021]; Physical Health [P = .032]), treatment alliance (WAI – Bond [patient-rated][P = .046]), illness perceptions (BIPQ – Consequence [P = .017]; BIPQ – Timeline [P = .011]; BIPQ – Treatment Control [P = .029]), and one performance-based measure (Walk Time [P = .007]). Similarly, patients in the Provider-Only group had better outcomes over time for multiple outcome domains; including, pain-related functioning/symptoms (PDQ [P = .033]; PROMIS Pain Interference [P = .031]; PROMIS Fatigue [P = .036]; PROMIS Physical Functioning [P = .049]), psychological and psychosocial variables (PMQ [opioid misuse risk][P = .041]), treatment alliance (WAI – Bond [patient-rated][P = .076]; WAI – Bond [provider-rated][P = .008]), illness perceptions (BIPQ – Timeline [P = .048]; BIPQ – Personal Control [P = .027]), and one performance-based measure (Walk Time [P = .035]). Comparisons between patients in the Dual Feedback and Provider-Only Feedback groups were significant for a few domain outcomes. Compared to Provider-Only Feedback, Dual Feedback had better outcomes over time for multiple domain measures; including, the PDQ (P = .085), PROMIS Anger (P = .000), PROMIS Anxiety (P = .018), and BIPQ – Treatment Control (P = .015). Conversely, the Provider-Only group had better outcome scores over time for PROMIS Global HrQOL (Mental Health (P = .032); Physical Health (P = .074). Analyses of process variables showed a mean completion time of 15.8 minutes for the entire assessment; completion-time statistics were also calculated for the 11 PROMIS computer-adaptive-tests (M = 7.57 minutes [all PROMIS CAT’s]; M = 41.3 second per measure, SD = 9.3 seconds) and other primary outcomes (PDQ, PMQ, BIPQ) (M = 8.23 minutes total; M = 2.74 minutes per measure, SD = .99 minutes). Conclusion: The provision of dual feedback (patient and providers) from PRO data collected prior to the point-of-care had an impact on several outcomes from multiple domains (pain-related functioning, psychological symptoms, psychosocial variables, illness perception, walking performance) over time, compared to patients who received no point-of-care feedback. To a lesser extent, group by time effects were also observed in comparisons between patients receiving provider-only feedback and those with no feedback. Brought together, high ecological validity was maintained with minimal disruption of clinic flow; likely contributing factors include the use of a set framework for outcome-tracking, protocol-based delivery of feedback, and efficiency of administration. This is the first study to show the potential benefits of providing PRO data feedback to both patients and providers prior to the point-of-care. [Keywords: chronic pain, patient-reported outcomes, biopsychosocial, patient feedback, computer-adaptive-testing, point-of-care, treatment outcomes, PROMIS]Item An Evaluation of the Predictive Validity of the Pain Medication Questionnaire With a Heterogeneous Group of Chronic Pain Patients(2006-08-11) Dowling, Leah Suzanne; Stowell, Anna W.The Pain Medication Questionnaire (PMQ) was initially developed by Adams and colleagues (2004) as a 26-item self-report assessment to screen for opioid medication misuse. The PMQ has demonstrated good reliability and validity, and was predictive of early termination from treatment and identified patients who demonstrated maximal benefit from interdisciplinary treatment (Holmes et al., 2006). This current study explored whether or not the initial PMQ score would accurately predict the development of aberrant opioid medication use behaviors relative to specific behavioral indices (i.e., request for early refills, use of a medication agreement) and a physician rating of medication misuse behaviors. Patients fell into two groups according to their initial score on the PMQ based on the median score of 25. Patients with higher PMQ (H-PMQ) scores reported greater levels of perceived disability and decreased physical and mental functioning. Total scores from the PMQ were moderately correlated with initial measures of physical and psychosocial functioning, and observed problematic medication use behaviors observed by physicians during evaluation. However, higher PMQ scores did not significantly predict the use of a medication agreement or requests for early refills. Five patients were identified from the H-PMQ group that demonstrated problematic opioid medication use that fell outside of the realm of early refill requests. These included utilizing leftover pain medications, taking narcotic medication prescribed to a family member, prescription forgery, and referral for detoxification. Although these patients varied on demographic variables, they each had a PMQ total score greater than 30. Indicating that although a PMQ total score ≥ 25 is indicative of problematic use, a score ≥ 30 suggests that a patient should be closely monitored when prescribed and opioid medication. Overall, this study demonstrated that a patient's self-report is significantly correlated with problematic behaviors observed by physicians. Therefore, when utilized in a busy clinic setting, the PMQ will aide in the identification of specific problematic behaviors and beliefs at the outset of treatment that may hinder successful treatment of a patient's pain condition.Item Multidimensional Pain Inventory: Revised Profile Classification Based on Clinical Observations in a Pain Setting(2005-08-11) Ravani, Payal Jitendra; Stowell, Anna WrightThe purpose of this study was to build a new profile classification system for the Multidimensional Pain Inventory (MPI). According to some clinical researchers, the current profiles of the MPI do not fully portray how chronic pain patients evaluate and manage their pain because of the great variability in each subgroup. This study tried to revise the current profile classifications based on clinical observations, which may then lead to facilitate improved patient assessment, professional communication, and treatment planning. Participants, who completed pre- and post- treatment MPI measures, were randomly selected from the interdisciplinary program at the Eugene McDermott Center for Pain Management at UT Southwestern Medical Center at Dallas. Two hundred and eighty patients were then assigned to three different groups depending upon the re-coded scores from their pre-treatment MPI. Patients were grouped according to their MPI subscale scores. In order to determine if the hypotheses were supported or not, paired t-test were completed on six different psychosocial and functional outcome measures. Analyses were also conducted to check for differences among the nine different groups. As postulated, a number of significant relationships were identified. Paired t-test analyses demonstrated the significance of the relationship between certain MPI subscales. When Pain Severity (PS) and Interference (I) were below average (as determined by recoded T scores), patients had a good prognosis. When Life Control (LC) equaled Affective Distress (AD), participants were seen to have a good prognosis as well. Associations between the other MPI subscales were also assessed, but data did not support those hypotheses. The majority of the outcomes did not meet expectation, because of several limitations with the study design.Item Pre-Surgical Behavioral Medicine Evaluation (PBME) for Implantable Devices for Pain Management : a One-Year Prospective Study(2006-08-11) Heckler, David Robert; Stowell, Anna W.Chronic pain affects millions of individuals around the world financially, physically, psychologically, and socially. When nonoperative care does not provide adequate pain relief, surgically invasive procedures are often considered. However, poor surgical outcome affect the patient, the physician, the employer, and the insurance company. In order to reduce negative surgical outcomes, pre-surgical psychological evaluations are used in order to better predict prognosis. The current study looked at the utility of the Presurgical Behavioral Medicine Evaluation (PBME) and revised algorithm that was described in Shocket's (2005) investigation that determines a patient's prognosis for invasive pain procedures. Patients were placed in a Green, Yellow I, Yellow II, or Red prognosis group, with Green having the best prognosis for surgery and Red having the worst prognosis. A total of 95 patients completed the PBME evaluation, with most patients being evaluated for a spinal cord stimulator or intrathecal pump. Variables, including gender, disability payment status, and involvement in pending litigation, were found to be significantly different among the groups. Analysis of data at the initial evaluation indicated that patients within the Red group endorsed significantly more physical/functional limitations, depressive symptomatology, and reported more psychological distress than the Green group. Patients were followed-up 6- and 12-months post-evaluation with both physical/functional and psychosocial measures. Analysis of the 12-month follow-up data indicated that there were significant differences among the four groups in terms of the VAS, BDI, MCS, OSW scores, and the catastrophizing scale on the CSQ. In addition, the Tukey HSD and Mann Whitney tests revealed specific significant differences among the groups. A repeated measures analysis of the initial evaluation, 6-month, and 12-month follow-up data revealed the Green and Red group was significantly different in terms of the VAS, OSW, BDI, and MCS. In addition, nonparametric analysis indicated that there were significant differences among the groups on total risk factor scores as determined by the PBME algorithm.