Marianne S. Matthias

BARRIERS AND FACILITATORS TO CHRONIC PAIN SELF-MANAGEMENT: A QUALITATIVE STUDY OF PRIMARY CARE PATIENTS WITH COMORBID MUSCULOSKELETAL PAIN AND DEPRESSION

OBJECTIVE To identify barriers and facilitators to self-management of chronic musculoskeletal pain among patients with comorbid pain and depression. DESIGN A qualitative study using focus group methodology. SETTING Veteran Affairs (VA) and University primary care clinics. PATIENTS Recruited after participation in a clinical trial. INTERVENTION The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) trial tested an intervention of optimized antidepressant therapy combined with a pain self-management program versus usual care for primary care patients with comorbid chronic pain and depression. OUTCOME MEASURES Thematic content analysis from focus group data was used to identify patient-perceived barriers and facilitators to self-management of chronic musculoskeletal pain. RESULTS Patients (N = 18) were 27 to 84 years old (M = 54.8), 61% women, 72% white, and 22% black. Barriers to pain self-management included: 1) lack of support from friends and family; 2) limited resources (e.g., transportation, financial); 3) depression; 4) ineffectiveness of pain-relief strategies; 5) time constraints and other life priorities; 6) avoiding activity because of fear of pain exacerbation; 7) lack of tailoring strategies to meet personal needs; 8) not being able to maintain the use of strategies after study completion; 9) physical limitations; and 10) difficult patient-physician interactions. Facilitators to improve pain self-management included 1) encouragement from nurse care managers; 2) improving depression with treatment; 3) supportive family and friends; and 4) providing a menu of different self-management strategies to use. CONCLUSIONS Future research is needed to confirm these findings and to design interventions that capitalize on the facilitators identified while at the same time addressing the barriers to pain self-management.

Re-thinking shared decision-making: Context matters

OBJECTIVE Traditional perspectives on shared decision-making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but also by the entire clinical encounter, and, even more broadly, by the nature of the patient-provider relationship. METHOD The four habits approach to effective clinical communication, a validated and widely used framework for patient-provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient-provider relationship. RESULTS The Four Habits consists of four categories of behaviors: (1) invest in the beginning; (2) elicit the patients perspective; (3) demonstrate empathy; and (4) invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM. CONCLUSION SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions. PRACTICE IMPLICATIONS SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework.

You and me and the computer makes three: variations in exam room use of the electronic health record.

Challenges persist on how to effectively integrate the electronic health record (EHR) into patient visits and clinical workflow, while maintaining patient-centered care. Our goal was to identify variations in, barriers to, and facilitators of the use of the US Department of Veterans Affairs (VA) EHR in ambulatory care workflow in order better to understand how to integrate the EHR into clinical work. We observed and interviewed 20 ambulatory care providers across three geographically distinct VA medical centers. Analysis revealed several variations in, associated barriers to, and facilitators of EHR use corresponding to different units of analysis: computer interface, team coordination/workflow, and organizational. We discuss our findings in the context of different units of analysis and connect variations in EHR use to various barriers and facilitators. Findings from this study may help inform the design of the next generation of EHRs for the VA and other healthcare systems.

Circumstances and consequences of falls among people with chronic stroke

Falls are common after stroke; however, circumstances and consequences are relatively unknown. Our objectives were to identify the differences between fallers and non-fallers among people with chronic stroke, identify the circumstances of fall events, and examine the consequences of the falls. This is a secondary data analysis; all participants included sustained a stroke. Variables included demographics, stroke characteristics, and comorbidities. Falls were collected via self-report, and circumstances and consequences were derived from participant description of the event and categorized as appropriate. Among 160 participants, 53 (33%) reported a fall during the 1 yr period. Circumstances of falls were categorized as intrinsic or extrinsic. Location and circumstance of the fall were included: 70% occurred at home and 40% were associated with impaired physical or mental state (e.g., inattention to tying shoes). Additionally, 21% of falls were associated with activities of daily living and mobility and 34% with slips or trips. The majority who fell sustained an injury (72%). Injuries ranged from bruising to fractures, and 55% of those with an injury sought medical care (32% to emergency department). Poststroke falls are associated with an alarming rate of injury and healthcare utilization. Targeting mental and physical states may be key to fall prevention.

Communicating about opioids for chronic pain: A qualitative study of patient attributions and the influence of the patient-physician relationship

Chronic pain poses numerous challenges for patients and providers, particularly when opioid treatment is discussed. Despite accounts of antagonistic patient–provider communication, little is known about how communication about opioids unfolds during clinic visits and, importantly, how the relationship history of a patient and physician shapes this communication. This studys objective was to advance understanding of communication about opioid treatment by recording primary care clinic visits and conducting in‐depth interviews with patients to gain insight into the patient–provider relationship and its influence on clinical communication.

A Coding System to Measure Elements of Shared Decision Making During Psychiatric Visits

OBJECTIVE Shared decision making is widely recognized to facilitate effective health care. The purpose of this study was to assess the applicability and usefulness of a scale to measure the presence and extent of shared decision making in clinical decisions in psychiatric practice. METHODS A coding scheme assessing shared decision making in general medical settings was adapted to mental health settings, and a manual for using the scheme was created. Trained raters used the adapted scale to analyze 170 audio-recordings of medication check-up visits with either psychiatrists or nurse practitioners. The scale assessed the level of shared decision making based on the presence of nine specific elements. Interrater reliability was examined, and the frequency with which elements of shared decision making were observed was documented. The association between visit length and extent of shared decision making was also examined. RESULTS Interrater reliability among three raters on a subset of 20 recordings ranged from 67% to 100% agreement for the presence of each of the nine elements of shared decision making and 100% for the agreement between provider and consumer on decisions made. Of the 170 sessions, 128 (75%) included a clinical decision. Just over half of the decisions (53%) met minimum criteria for shared decision making. Shared decision making was not related to visit length after the analysis controlled for the complexity of the decision. CONCLUSIONS The rating scale appears to reliably assess shared decision making in psychiatric practice and could be helpful for future research, training, and implementation efforts.

Predictors of Shared Decision Making and Level of Agreement Between Consumers and Providers in Psychiatric Care

The purpose of this study was to quantitatively examine elements of shared decision making (SDM), and to establish empirical evidence for factors correlated with SDM and the level of agreement between consumer and provider in psychiatric care. Transcripts containing 128 audio-recorded medication check-up visits with eight providers at three community mental health centers were rated using the Shared Decision Making scale, adapted from Braddock’s Informed Decision Making Scale (Braddock et al. 1997, 1999, 2008). Multilevel regression analyses revealed that greater consumer activity in the session and greater decision complexity significantly predicted the SDM score. The best predictor of agreement between consumer and provider was “exploration of consumer preference,” with a four-fold increase in full agreement when consumer preferences were discussed more completely. Enhancing active consumer participation, particularly by incorporating consumer preferences in the decision making process appears to be an important factor in SDM.

Factors influencing patients’ preferences and perceived involvement in shared decision-making in mental health care

Abstract Background: Although research has suggested that patients desire to participate in shared decision-making, recent studies show that most patients take a passive role in their treatment decisions. The discrepancy between patients’ expressed desire and actual behaviors underscores the need to better understand how patients perceive shared decision-making and what factors influence their participation. Aims: To investigate patients’ preferences and appraisals of their involvement in treatment decisions. Methods: Fifty-four qualitative interviews were conducted with veterans receiving outpatient mental health care at a U.S. Veterans Affairs Medical Center. Interviews were analyzed using thematic analysis. Results: Participants outlined several factors that influence their preferences and involvement in treatment decisions. These include the patient–provider relationship, fear of being judged, perceived inadequacy, and a history of substance abuse. Conclusion: Patients’ preferences and willingness to engage in shared decision-making fluctuate over time and are context dependent. A better understanding of these factors and a strong patient–provider relationship will facilitate better measurement and implementation of shared decision-making.

Patients’ Understanding of Shared Decision Making in a Mental Health Setting

Shared decision making is a fundamental component of patient-centered care and has been linked to positive health outcomes. Increasingly, researchers are turning their attention to shared decision making in mental health; however, few studies have explored decision making in these settings from patients’ perspectives. We examined patients’ accounts and understanding of shared decision making. We analyzed interviews from 54 veterans receiving outpatient mental health care at a Department of Veterans Affairs Medical Center in the United States. Although patients’ understanding of shared decision making was consistent with accounts published in the literature, participants reported that shared decision making goes well beyond these components. They identified the patient–provider relationship as the bedrock of shared decision making and highlighted several factors that interfere with shared decision making. Our findings highlight the importance of the patient–provider relationship as a fundamental element of shared decision making and point to areas for potential improvement.

The Patient–Provider Relationship in Chronic Pain Management: Where Do We Go From Here?

Ask any clinician which patients he or she considers the most difficult to manage, and odds are patients with chronic pain will top the list. Anecdotal reports abound detailing the challenges such patients pose for providers. The limited published research in patient–provider communication in chronic pain care corroborates these anecdotal reports, telling of adversarial, unproductive clinic visits, often characterized by competing demands between patients and providers [1], struggles for dominance and control [2], and mutual lack of trust [3]. Research has described a “burdened physician–patient relationship”[4] and power struggles between patients with chronic pain and their providers [2,5]. Such problematic relationships pose significant challenges for providers, who have described caring for patients with pain as a “thankless” task, in which they are “confronted with failure” every day [5]. In managing patients with fibromyalgia, physicians described interactions as time-consuming, demanding, and emotionally challenging [4]. In a VA study, 73% of providers surveyed considered caring for patients with chronic pain a “major source of frustration”[6]. Patients, too, feel the relational strain prevalent in chronic pain care. In one study, female patients with chronic pain described actively working to establish credibility with their physicians, characterizing their interactions as “strenuous,”“complicated,” and “heavy.”[3] Patients may experience stress, depression, anxiety, and feelings of alienation when PCPs do not believe their pain complaints or when they perceive that they have not received adequate information about their condition and its treatment [5,7,8]. Staiger et al. found that when patients with back pain disagreed with their physicians about the cause of their pain, or the recommended diagnostic and treatment plans, patients reported decreased satisfaction with care …