Patient-centered medical homes bested others in chronic pain management

NEW YORK– Certified patient-centered medical homes were significantly more likely to adhere to pain management guidelines than were uncredentialed primary care practices, a retrospective study has shown.

Because patient-centered medical homes are predicated on safety and quality, coordination and integration, Dr. Nancy C. Elder, professor and director of research in the department of family and community medicine at the University of Cincinnati, said that they were already focused on primary care pain process guidelines for managing musculoskeletal pain established in 2011.

“A team, multidisciplinary approach to care, typical of a medical home, is generally associated with better pain outcomes,” Dr. Elder told a standing-room only crowd at the chronic pain research track of the annual meeting of the North American Primary Care Research Group.

Still, there are few data to support a direct correlation between patient-centered medical home (PCMH) protocols as defined by the National Committee for Quality Assurance and how chronic pain is managed.

To address that gap, Dr. Elder and her associates conducted a random review of 485 charts of chronic pain patients seen at least twice at one of 12 academic-affiliated primary care practices in a 12-month period. Three of the practices had achieved PCMH certification in 2010, five were certified in 2013 prior to the study, and four clinics had no medical home certification. There was one internal medicine residency, while the rest were a combination of either family and internal medicine or internal medicine and pediatrics practices. Between 6 to 15 charts were reviewed per provider, although per office the range was between 10 and 95 charts. Charts from experienced PCMH clinics numbered 128, while newer PCMH-certified-clinic charts numbered 242. There were 115 non–PCMH clinic chart reviews.

Patients across all three clinic groups ranged in age from 56 years to 61.6 years and were predominantly white women.

The non-PCMH offices, when compared with the certified clinics, were significantly less likely to document four of eight key data points to assess and manage chronic pain, including a patient’s pain severity (39% vs. 75%, P less than .001), functional disability (41% vs. 66%, P less than .001), psychosocial distress (38% vs. 54%, P = .01), or substance abuse (13% vs. 32%, P less than .001).

All clinics were inclined to address depression and employ nonpharmacologic approaches to pain, although opioids were prescribed chronically 57% of the time, regardless of PCMH certification status. All clinics were equally likely to ask patients to enter into an opioid-use contract, but noncertified practices were less likely to assess patients for the side effects of opioid use (56% vs. 68%, P = .02), perform a urine drug screen (27% vs. 48%), or review a state controlled-prescription report (38% vs. 50%, P = .005).

Although Dr. Elder concluded that the medical home model is conducive to better chronic pain management, the actual relationship between protocols and patient outcomes is still unknown. She also noted that, although there was not a statistically significant difference, practices that had been PCMH certified the longest did not perform as well as the practices with newer certification.

“That raised the question about whether some of the skills and benefits of becoming a PCMH wane with time,” she said.

Dr. Elder did not state any relevant disclosures.

[email protected]

On Twitter @whitneymcknight

NEW YORK– Certified patient-centered medical homes were significantly more likely to adhere to pain management guidelines than were uncredentialed primary care practices, a retrospective study has shown.

Because patient-centered medical homes are predicated on safety and quality, coordination and integration, Dr. Nancy C. Elder, professor and director of research in the department of family and community medicine at the University of Cincinnati, said that they were already focused on primary care pain process guidelines for managing musculoskeletal pain established in 2011.

“A team, multidisciplinary approach to care, typical of a medical home, is generally associated with better pain outcomes,” Dr. Elder told a standing-room only crowd at the chronic pain research track of the annual meeting of the North American Primary Care Research Group.

Still, there are few data to support a direct correlation between patient-centered medical home (PCMH) protocols as defined by the National Committee for Quality Assurance and how chronic pain is managed.

To address that gap, Dr. Elder and her associates conducted a random review of 485 charts of chronic pain patients seen at least twice at one of 12 academic-affiliated primary care practices in a 12-month period. Three of the practices had achieved PCMH certification in 2010, five were certified in 2013 prior to the study, and four clinics had no medical home certification. There was one internal medicine residency, while the rest were a combination of either family and internal medicine or internal medicine and pediatrics practices. Between 6 to 15 charts were reviewed per provider, although per office the range was between 10 and 95 charts. Charts from experienced PCMH clinics numbered 128, while newer PCMH-certified-clinic charts numbered 242. There were 115 non–PCMH clinic chart reviews.

Patients across all three clinic groups ranged in age from 56 years to 61.6 years and were predominantly white women.

The non-PCMH offices, when compared with the certified clinics, were significantly less likely to document four of eight key data points to assess and manage chronic pain, including a patient’s pain severity (39% vs. 75%, P less than .001), functional disability (41% vs. 66%, P less than .001), psychosocial distress (38% vs. 54%, P = .01), or substance abuse (13% vs. 32%, P less than .001).

All clinics were inclined to address depression and employ nonpharmacologic approaches to pain, although opioids were prescribed chronically 57% of the time, regardless of PCMH certification status. All clinics were equally likely to ask patients to enter into an opioid-use contract, but noncertified practices were less likely to assess patients for the side effects of opioid use (56% vs. 68%, P = .02), perform a urine drug screen (27% vs. 48%), or review a state controlled-prescription report (38% vs. 50%, P = .005).

Although Dr. Elder concluded that the medical home model is conducive to better chronic pain management, the actual relationship between protocols and patient outcomes is still unknown. She also noted that, although there was not a statistically significant difference, practices that had been PCMH certified the longest did not perform as well as the practices with newer certification.

“That raised the question about whether some of the skills and benefits of becoming a PCMH wane with time,” she said.

Dr. Elder did not state any relevant disclosures.

[email protected]

On Twitter @whitneymcknight

NEW YORK– Certified patient-centered medical homes were significantly more likely to adhere to pain management guidelines than were uncredentialed primary care practices, a retrospective study has shown.

Because patient-centered medical homes are predicated on safety and quality, coordination and integration, Dr. Nancy C. Elder, professor and director of research in the department of family and community medicine at the University of Cincinnati, said that they were already focused on primary care pain process guidelines for managing musculoskeletal pain established in 2011.

“A team, multidisciplinary approach to care, typical of a medical home, is generally associated with better pain outcomes,” Dr. Elder told a standing-room only crowd at the chronic pain research track of the annual meeting of the North American Primary Care Research Group.

Still, there are few data to support a direct correlation between patient-centered medical home (PCMH) protocols as defined by the National Committee for Quality Assurance and how chronic pain is managed.

To address that gap, Dr. Elder and her associates conducted a random review of 485 charts of chronic pain patients seen at least twice at one of 12 academic-affiliated primary care practices in a 12-month period. Three of the practices had achieved PCMH certification in 2010, five were certified in 2013 prior to the study, and four clinics had no medical home certification. There was one internal medicine residency, while the rest were a combination of either family and internal medicine or internal medicine and pediatrics practices. Between 6 to 15 charts were reviewed per provider, although per office the range was between 10 and 95 charts. Charts from experienced PCMH clinics numbered 128, while newer PCMH-certified-clinic charts numbered 242. There were 115 non–PCMH clinic chart reviews.

Patients across all three clinic groups ranged in age from 56 years to 61.6 years and were predominantly white women.

The non-PCMH offices, when compared with the certified clinics, were significantly less likely to document four of eight key data points to assess and manage chronic pain, including a patient’s pain severity (39% vs. 75%, P less than .001), functional disability (41% vs. 66%, P less than .001), psychosocial distress (38% vs. 54%, P = .01), or substance abuse (13% vs. 32%, P less than .001).

All clinics were inclined to address depression and employ nonpharmacologic approaches to pain, although opioids were prescribed chronically 57% of the time, regardless of PCMH certification status. All clinics were equally likely to ask patients to enter into an opioid-use contract, but noncertified practices were less likely to assess patients for the side effects of opioid use (56% vs. 68%, P = .02), perform a urine drug screen (27% vs. 48%), or review a state controlled-prescription report (38% vs. 50%, P = .005).

Although Dr. Elder concluded that the medical home model is conducive to better chronic pain management, the actual relationship between protocols and patient outcomes is still unknown. She also noted that, although there was not a statistically significant difference, practices that had been PCMH certified the longest did not perform as well as the practices with newer certification.

“That raised the question about whether some of the skills and benefits of becoming a PCMH wane with time,” she said.

Dr. Elder did not state any relevant disclosures.

[email protected]

On Twitter @whitneymcknight