Clinical Research Study
Pain Management in Primary Care: A Randomized Controlled Trial of a Computerized Decision Support Tool

https://doi.org/10.1016/j.amjmed.2021.07.014Get rights and content

Abstract

Background

Primary care providers manage most patients with chronic pain. Pain is a complex problem, particularly in underserved populations. A technology-enabled, point-of-care decision support tool may improve pain management outcomes.

Methods

We created an electronic health record (EHR)-based decision support tool, the Pain Management Support System–Primary Care (PMSS-PC), and studied the tool-plus-education in 6 Federally Qualified Health Center practices using a randomized, wait-list controlled design. The PMSS-PC generated “best practice alerts,” gave clinicians access to a pain assessment template, psychological distress and substance use measures, guidelines for drug and non-drug therapies, and facilitated referrals. Practices were randomly assigned to early vs delayed (after 6 months) implementation of the intervention, including technical support and 6 webinars. The primary outcome was change in worst pain intensity scores after 6 months, assessed on the Brief Pain Inventory-Short Form. Changes in outcomes were compared between the practices using linear multilevel modeling. The EHR provided clinician data on PMSS-PC utilization.

Results

The 256 patients in the early implementation practices had significantly improved worst pain (standardized effect size [ES] = −.32) compared with the 272 patients in the delayed implementation practices (ES = −.11). There was very low clinician uptake of the intervention in both conditions.

Conclusions

Early implementation of the PMSS-PC improved worst pain, but this effect cannot be attributed to clinician use of the tool. Further PMSS-PC development is not indicated, but practice-level interventions can improve pain, and studies are needed to identify the determinants of change.

Introduction

Chronic pain is a complex condition associated with numerous diagnoses and diverse psychosocial and functional consequences. Most patients with chronic pain are treated by primary care providers (PCPs), who must integrate pain therapies with interventions for disease management and other conditions affecting quality of life while addressing factors associated with health outcomes, such as health literacy and social determinants of illness.1,2 The latter factors may be particularly prevalent in economically disadvantaged populations, like those enrolled in US Federally Qualified Health Center (FQHC) networks.

PCPs may rely on treatment guidelines to implement best practices in pain management. These guidelines change over time, however, and rarely reflect the challenges encountered in specific treatment settings. PCPs may benefit from improved access to setting-specific and up-to-date pain management guidelines.

Recent work suggests that technology-enabled decision support tools are useful to promote guideline-informed practices for complex clinical conditions.3,4 These tools can be customized for the FQHC setting and offer point-of-care information that could potentially improve pain-related outcomes.

Section snippets

Methods

We developed an electronic health record (EHR)-based decision support tool for pain management by PCPs in an FQHC—the Pain Management Support System–Primary Care (PMSS-PC)—and evaluated whether practice level access to the tool plus education improved pain outcomes.

Results

A total of 615 patients were screened, 562 were eligible, and 529 consented; one was subsequently excluded due to age <18 years. The analysis sample included 256 patients receiving care in the early implementation practices and 272 patients receiving care in the delayed implementation practices. Between Time 0 and Time 1, 103 patients were lost to follow-up, including 46 who were receiving care in the early implementation practices and 57 who were receiving care in the delayed implementation

Discussion

We designed an EHR-based decision support tool for pain management for PCPs in an FQHC network and evaluated the tool and accompanying education in a randomized wait-list controlled trial. The trial evaluated the hypothesis that a practice-level intervention would garner positive patient-level pain outcomes22 and that this improvement would be associated with clinician use of the tool.

The trial revealed that one important outcome, worst pain intensity, significantly improved for 6 months after

Conclusion

Although a practice-level intervention comprising an EHR-based decision support tool-plus-education improved worst pain in a population with chronic pain served by an FQHC network, the improvement could not be attributed to use of the technology. This study does not support continued development of the PMSS-PC, but underscores the need for additional research to identify the most salient determinants of practice change and the development of new strategies to improve pain management in primary

Acknowledgment

We gratefully acknowledge Malcolm Barrett for his assistance with data collection.

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  • Funding: This work was supported by a grant from Pfizer's Office of Independent Grants for Learning and Change (8408357; RP).

    Conflicts of Interest: There are no competing interests declared.

    Authorship: All authors had access to the data and a role in writing this manuscript.

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