Primary Care Clinician Adherence to Guidelines for the Management of Chronic Musculoskeletal Pain: Results from the Study of the Effectiveness of a Collaborative Approach to Pain
Primary Care Clinician Adherence to Guidelines for the Management of Chronic Musculoskeletal Pain: Results from the Study of the Effectiveness of a Collaborative Approach to Pain
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DOI：
10.1111/j.1526-4637.2011.01231.x
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发表时间：
2011-01-01
期刊：
影响因子：
3.1
通讯作者：
Dobscha, Steven K.
中科院分区：
文献类型：
--
作者：
Corson, Kathryn;Doak, Melanie N.;Dobscha, Steven K.
Objective.我们评估了患者病历中记录的初级保健医生提供的指南一致性护理、记录的指南一致性护理的预测因素及其与疼痛相关功能的关联。患者参加了一项慢性肌肉骨骼疼痛的合作护理随机试验。干预的特点是患者和初级保健临床医生的教育，症状监测和反馈给临床医生的干预小组。为了评估与循证治疗指南的一致性，我们开发了一个8项图表审查工具，疼痛过程检查表（PPC）。然后，我们审查了365名退伍军人患者的电子病历，这些患者由42名初级保健临床医生在12个月内治疗。使用广义估计方程（GEE）对干预状态、人口统计学和临床变量作为PPC评分的预测因子进行了检验。GEE还用于检验PPC评分是否预测治疗反应（Roland-Morris残疾问卷评分下降>= 30%）。PPC项目中记录的指南一致性护理的比率差异很大，从94%的患者有疼痛到17%的阿片类药物患者有副作用。干预状态与项目评分无关，干预组和常规治疗组患者的PPC-7总数无显著差异（61.2%，标准误[SE] = 3.3% vs 55.2%，SE = 2.6%，P = 0.15）。在多变量模型中，较高的PPC-7评分与接受阿片类药物处方相关（比值比[OR] = 1.07，P = 0.007），较低的PPC-7评分与患者年龄相关（10岁差异OR = 0.97，P = 0.004）。最后，接受定量疼痛和抑郁评估的干预患者对治疗的反应较低（评估与未评估：分别为18%与33%，P = 0.008和13%与28%，P = 0.001）。通过病历审查，额外的培训和临床医生反馈并没有增加记录的指南一致的疼痛护理的提供，初级保健临床医生遵守指南并没有改善慢性肌肉骨骼疼痛患者的临床结局。
Objective. We assessed primary care clinician-provided guideline-concordant care as documented in patients' medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team.Methods. To assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (>= 30% decrease in Roland-Morris Disability Questionnaire score).Results. Rates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively).Conclusions. As measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.